Provider Demographics
NPI:1962170910
Name:MORTENSON, MITCHEL JAMES (AAC)
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:JAMES
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 PACIFIC AVE N
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-3300
Mailing Address - Country:US
Mailing Address - Phone:360-642-3787
Mailing Address - Fax:
Practice Address - Street 1:2204 PACIFIC AVE N
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3300
Practice Address - Country:US
Practice Address - Phone:360-642-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1760008783Medicaid