Provider Demographics
NPI:1336508159
Name:MORTENSEN, MCKENZIE (MS OTR/L)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 S MAPLE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3838
Mailing Address - Country:US
Mailing Address - Phone:734-369-6002
Mailing Address - Fax:
Practice Address - Street 1:635 S MAPLE RD STE 2
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3838
Practice Address - Country:US
Practice Address - Phone:734-369-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11840225X00000X
AZ6475225X00000X
MI5201012978225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist