Healthcare Provider Details

I. General information

NPI: 1740096619
Provider Name (Legal Business Name): DENITA L MORTENSEN ACMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 BUSINESS PARK DR
OREM UT
84058-2204
US

IV. Provider business mailing address

1154 DOVER DR
PROVO UT
84604-5240
US

V. Phone/Fax

Practice location:
  • Phone: 801-494-4335
  • Fax:
Mailing address:
  • Phone: 801-494-4335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number141748846009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: