Provider Demographics
NPI:1871637876
Name:MORTENSEN, AMBERLEY NOEL (LATC)
Entity Type:Individual
Prefix:
First Name:AMBERLEY
Middle Name:NOEL
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 VT ROUTE 100
Mailing Address - Street 2:HARWOOD UNION HIGH SCHOOL
Mailing Address - City:SOUTH DUXBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05660-9128
Mailing Address - Country:US
Mailing Address - Phone:802-882-1121
Mailing Address - Fax:802-882-1198
Practice Address - Street 1:458 VT ROUTE 100
Practice Address - Street 2:HARWOOD UNION HIGH SCHOOL
Practice Address - City:SOUTH DUXBURY
Practice Address - State:VT
Practice Address - Zip Code:05660-9128
Practice Address - Country:US
Practice Address - Phone:802-882-1121
Practice Address - Fax:802-882-1198
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104-0000130174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist