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General NPI Number Information
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NPI Number | 1104312974
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Entity Type | Individual
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Provider Name | MISTY L MORTENSEN
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Gender | Female
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Dates
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Enumeration Date | 07/05/2018
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Last Update Date | 11/13/2018
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Provider Practice Location Address
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Address Line | 551 LONE PINE BLVD
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City | THE DALLES
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State | OR
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Zip | 97058-9403
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Country | US
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Telephone | 541-506-5779
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Fax |
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Provider Business Mailing Address
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Address Line | 693 DRY CREEK RD
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City | MOSIER
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State | OR
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Zip | 97040-9772
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Country | US
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Telephone | 530-260-0995
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | COS-FT-10118887
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License Number State | OR
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