Provider Demographics
NPI:1952436214
Name:MORTENSON, SAUNDRA L (LCSW)
Entity type:Individual
Prefix:
First Name:SAUNDRA
Middle Name:L
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 S 11TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4736
Mailing Address - Country:US
Mailing Address - Phone:219-861-6156
Mailing Address - Fax:
Practice Address - Street 1:3130 S 11TH ST
Practice Address - Street 2:STE 103
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4736
Practice Address - Country:US
Practice Address - Phone:219-861-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000157A1041C0700X
MI68011064201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI15576OtherMI MEDICARE
IN000000354655OtherBCBS
IN085600000OtherMAGELLAN