Provider Demographics
NPI:1720125636
Name:MORTENSEN, TRISTA NICOLE (MSW)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:NICOLE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 MAIN AVE S
Mailing Address - Street 2:STE 102
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2758
Mailing Address - Country:US
Mailing Address - Phone:206-697-3281
Mailing Address - Fax:206-358-5753
Practice Address - Street 1:304 MAIN AVE S
Practice Address - Street 2:STE 102
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2758
Practice Address - Country:US
Practice Address - Phone:206-697-3281
Practice Address - Fax:206-358-5753
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW600041751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2076299Medicaid