Provider Demographics
NPI:1962809467
Name:SHORT, KACIE NICOLE (OTA/L)
Entity type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:NICOLE
Last Name:SHORT
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:NICOLE
Other - Last Name:SCHABEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA/L
Mailing Address - Street 1:516 ONE CENTER BLVD
Mailing Address - Street 2:APT. 203
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-2229
Mailing Address - Country:US
Mailing Address - Phone:847-809-1185
Mailing Address - Fax:
Practice Address - Street 1:516 ONE CENTER BLVD
Practice Address - Street 2:APT. 203
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-2229
Practice Address - Country:US
Practice Address - Phone:847-809-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14141224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant