Provider Demographics
NPI:1790534964
Name:MORTENSEN, DONNA JOANNE (CSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:JOANNE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6699 SOUTHFORK RD
Mailing Address - Street 2:
Mailing Address - City:PROVO CANYON
Mailing Address - State:UT
Mailing Address - Zip Code:84604-9634
Mailing Address - Country:US
Mailing Address - Phone:385-208-9306
Mailing Address - Fax:
Practice Address - Street 1:437 E 1000 S STE 200
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3623
Practice Address - Country:US
Practice Address - Phone:801-921-3619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13407735-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker