Provider Demographics
NPI:1851375836
Name:MORTELLARO, DAVID L (LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:MORTELLARO
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6980 HIGHFIELDS FARM CIR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5631
Mailing Address - Country:US
Mailing Address - Phone:540-774-4114
Mailing Address - Fax:540-772-8242
Practice Address - Street 1:4656 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3437
Practice Address - Country:US
Practice Address - Phone:540-772-8043
Practice Address - Fax:540-772-8242
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001496101YM0800X
VA0717000603106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005400431OtherVIRGINIA PREMIER (HMO)
VA005400431Medicaid
VA297608000OtherMAGELLAN
VA087620OtherSOUTHERN HEALTH/SENTARA
VAJOHN DEEREOtherVA0101
VA018061OtherVALUE OPTIONS
VA132303OtherMANAGED HEALTH NETWORK
VA349980OtherMAMSI
VA285978OtherANTHEM BCBS
VA5675123OtherAETNA
VA69554OtherCIGNA BEHAVIORAL HEALTH