Healthcare Provider Details

I. General information

NPI: 1770643975
Provider Name (Legal Business Name): LISA MORTENSEN MS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S 100 E STE 102
PLEASANT GROVE UT
84062-2751
US

IV. Provider business mailing address

1915 W 140 S
OREM UT
84058-2062
US

V. Phone/Fax

Practice location:
  • Phone: 801-785-9991
  • Fax: 801-785-9417
Mailing address:
  • Phone: 801-812-2736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6332468-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: