Provider Demographics
NPI:1306985924
Name:SHORT, HEIDI S (BA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:S
Last Name:SHORT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6368
Mailing Address - Country:US
Mailing Address - Phone:802-257-0191
Mailing Address - Fax:
Practice Address - Street 1:17 93RD ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3748
Practice Address - Country:US
Practice Address - Phone:603-357-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NH171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator