Healthcare Provider Details

I. General information

NPI: 1720209240
Provider Name (Legal Business Name): MICHELLE LEE MORTENSEN MT-BC, NMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 S. FIRST ST.
PRINCETON IL
61356
US

IV. Provider business mailing address

115 WEST SEMINOLE ST.
DWIGHT IL
60420-1151
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-5848
  • Fax: 815-875-5848
Mailing address:
  • Phone: 815-584-2246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number07735
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: