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General NPI Number Information
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NPI Number | 1467732172
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Entity Type | Individual
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Provider Name | MELODY M MORTENSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/25/2011
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Last Update Date | 10/01/2019
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Provider Practice Location Address
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Address Line | 4241 N GABEL DR STE 2B
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5296
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Country | US
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Telephone | 479-879-2115
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Fax | 479-249-6989
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Provider Business Mailing Address
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Address Line | PO BOX 555
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City | FAYETTEVILLE
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State | AR
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Zip | 72702-0555
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Country | US
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Telephone | 479-879-2115
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2551-C
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License Number State | AR
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