Provider Demographics
NPI:1730523150
Name:MORTIMER, MILDRED
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:MORTIMER
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 1:16539 LAKE BRIGADOON CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1146
Mailing Address - Country:US
Mailing Address - Phone:813-579-2212
Mailing Address - Fax:813-345-2896
Practice Address - Street 1:16539 LAKE BRIGADOON CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-1146
Practice Address - Country:US
Practice Address - Phone:813-579-2212
Practice Address - Fax:813-345-2896
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker