Provider Demographics
NPI:1548009459
Name:MORTENSEN, MELLISA LYNN
Entity type:Individual
Prefix:
First Name:MELLISA
Middle Name:LYNN
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47-372 KAPEHE ST # A
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-4810
Mailing Address - Country:US
Mailing Address - Phone:385-346-9857
Mailing Address - Fax:
Practice Address - Street 1:203 KAPAA QUARRY PLACE
Practice Address - Street 2:5002
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-247-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician