Provider Demographics
NPI:1811775968
Name:MORTENSON, TERESIA (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:TERESIA
Middle Name:
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14399 ANDERSEN DR
Mailing Address - Street 2:
Mailing Address - City:CROSSLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442-3500
Mailing Address - Country:US
Mailing Address - Phone:218-839-2869
Mailing Address - Fax:
Practice Address - Street 1:401 W LAUREL ST STE C
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3970
Practice Address - Country:US
Practice Address - Phone:218-454-3288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN97281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical