Provider Demographics
NPI:1336925643
Name:MORTENSEN, MARISSA (DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7979 W RIFLEMAN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9066
Mailing Address - Country:US
Mailing Address - Phone:208-377-3850
Mailing Address - Fax:
Practice Address - Street 1:16816 N MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5140
Practice Address - Country:US
Practice Address - Phone:208-461-9593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist