Basic Information
| Provider Information | |||||||||
| NPI: | 1407802564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 S 108TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532271107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147744200 | ||||||||
| FaxNumber: | 4147746828 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 S 108TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532271107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147744200 | ||||||||
| FaxNumber: | 4147746828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 05/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 365-156 | WI | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.