MEDICARE: DONNA JOANNE MORTENSEN CSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	13407735-3502	UT

General Provider Information

NPI Number	:	1790534964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA JOANNE MORTENSEN CSW

Provider Business Mailing Address
First Line	:	6699 SOUTHFORK RD
Second Line	:
City	:	PROVO CANYON
State	:	UT
Zip	:	84604-9634
Country	:	US
Telephone Number	:	385-208-9306
Fax Number	:

Provider Business Practice Location Address
First Line	:	437 E 1000 S STE 200
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-3623
Country	:	US
Telephone Number	:	801-921-3619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2024
Last Update Date	:	05/18/2024

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