Provider Demographics
NPI:1447685789
Name:MORTENSEN, LISA KIRSTINE (MSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KIRSTINE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2588
Mailing Address - Country:US
Mailing Address - Phone:231-876-6527
Mailing Address - Fax:231-876-6519
Practice Address - Street 1:500 N WARREN AVE RM C
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1459
Practice Address - Country:US
Practice Address - Phone:231-796-9965
Practice Address - Fax:231-796-4950
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010793411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical