1720125636 NPI number — TRISTA NICOLE MORTENSEN MSW

Table of content: TRISTA NICOLE MORTENSEN MSW (NPI 1720125636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720125636 NPI number — TRISTA NICOLE MORTENSEN MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORTENSEN
Provider First Name:
TRISTA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720125636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 MAIN AVE S
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98057-2758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-697-3281
Provider Business Mailing Address Fax Number:
206-358-5753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 MAIN AVE S
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98057-2758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-697-3281
Provider Business Practice Location Address Fax Number:
206-358-5753
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LW60004175 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2076299 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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