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General NPI Number Information
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NPI Number | 1568376754
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Entity Type | Individual
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Provider Name | MATTHEW MORTENSEN
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Gender |
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Dates
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Enumeration Date | 10/02/2026
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Last Update Date | 10/02/2026
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Provider Practice Location Address
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Address Line | 602 SOUTH ST
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City | CHARDON
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State | OH
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Zip | 44024-1499
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Country | US
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Telephone | 440-251-2406
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Fax |
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Provider Business Mailing Address
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Address Line | 7106 BARTON DR
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City | MENTOR
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State | OH
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Zip | 44060-4409
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Country | US
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Telephone |
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | S-2614681
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License Number State | OH
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