Provider Demographics
NPI:1396092722
Name:MORTENSEN, MARISSA R (DPT)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:R
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 1:5050 SEDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60192-3712
Mailing Address - Country:US
Mailing Address - Phone:847-854-8219
Mailing Address - Fax:847-854-8278
Practice Address - Street 1:5050 SEDGE BLVD
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60192-3712
Practice Address - Country:US
Practice Address - Phone:847-854-8219
Practice Address - Fax:847-854-8278
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-019194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist