Provider Demographics
NPI:1215676812
Name:SHORT, KATHERINE SUZANNE (PTA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUZANNE
Last Name:SHORT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:SUZANNE
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SWANSON
Mailing Address - Street 1:556 KENSINGTON
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72718-5013
Mailing Address - Country:US
Mailing Address - Phone:479-430-0350
Mailing Address - Fax:
Practice Address - Street 1:2510 W HUDSON RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-2072
Practice Address - Country:US
Practice Address - Phone:479-936-1061
Practice Address - Fax:855-812-1132
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant