Provider Demographics
NPI:1083185672
Name:SHORT HAFLEY, CASSIDY
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:SHORT HAFLEY
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 1:172 BERLIN CT
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2282
Mailing Address - Country:US
Mailing Address - Phone:216-924-0847
Mailing Address - Fax:
Practice Address - Street 1:120 E TRINITY PL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3302
Practice Address - Country:US
Practice Address - Phone:404-378-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-08
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health