Provider Demographics
NPI:1538604681
Name:DR TERRI MORTENSEN
Entity type:Organization
Organization Name:DR TERRI MORTENSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-417-6545
Mailing Address - Street 1:4900 S UNIVERSITY DR
Mailing Address - Street 2:STE 200 D
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3808
Mailing Address - Country:US
Mailing Address - Phone:954-417-6545
Mailing Address - Fax:
Practice Address - Street 1:4900 S UNIVERSITY DR
Practice Address - Street 2:STE 200 D
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3808
Practice Address - Country:US
Practice Address - Phone:954-417-6545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7594251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health