Provider Demographics
NPI:1124440813
Name:SHORT, PATRICIA (LPC)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 NE LOOKOUT AVE
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1317
Mailing Address - Country:US
Mailing Address - Phone:971-312-2091
Mailing Address - Fax:
Practice Address - Street 1:185 NE 4TH ST STE 5
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1934
Practice Address - Country:US
Practice Address - Phone:971-312-2091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
ORC5788101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1124440813OtherNPI