Provider Demographics
NPI:1992803431
Name:MORTENSEN, MARIE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 DUBLIN BLVD.
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918
Mailing Address - Country:US
Mailing Address - Phone:719-331-6754
Mailing Address - Fax:719-488-1864
Practice Address - Street 1:1880 DUBLIN BLVD.
Practice Address - Street 2:SUITE D
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-331-6754
Practice Address - Fax:719-488-1864
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health