Provider Demographics
NPI:1851942718
Name:MORTENSEN, DALLY
Entity type:Individual
Prefix:
First Name:DALLY
Middle Name:
Last Name:MORTENSEN
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 1:4432 W 1525 S
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4432 W 1525 S
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-4631
Practice Address - Country:US
Practice Address - Phone:435-619-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9852658-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist