Healthcare Provider Details

I. General information

NPI: 1033484381
Provider Name (Legal Business Name): MONIQUE A MORT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6344 E BROADWAY RD STE 107
MESA AZ
85206-1634
US

IV. Provider business mailing address

6344 E BROADWAY RD STE 107
MESA AZ
85206-1634
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-0910
  • Fax:
Mailing address:
  • Phone: 602-888-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13860
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: