Provider Demographics
NPI:1538179692
Name:MORTENSEN, MARGARET R (PHD)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:R
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2765
Mailing Address - Country:US
Mailing Address - Phone:321-327-5952
Mailing Address - Fax:321-327-5954
Practice Address - Street 1:2401 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2765
Practice Address - Country:US
Practice Address - Phone:321-327-5952
Practice Address - Fax:321-327-5954
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4165103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
090953OtherVALUE OPTIONS
FL59560Medicare PIN