Provider Demographics
NPI:1972090207
Name:MORTENSEN, LEAH PLAISIER
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:PLAISIER
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 1:1635 N WATER ST APT 424
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3661
Mailing Address - Country:US
Mailing Address - Phone:414-731-7457
Mailing Address - Fax:
Practice Address - Street 1:3111 W RAWSON AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9417
Practice Address - Country:US
Practice Address - Phone:414-260-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI81997208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program