Provider Demographics
NPI:1033531454
Name:SHORT, COLLEEN ACADIA (LMFT, LMHC)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:ACADIA
Last Name:SHORT
Suffix:
Gender:F
Credentials:LMFT, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 COUNTY ROAD 337
Mailing Address - Street 2:
Mailing Address - City:DE BERRY
Mailing Address - State:TX
Mailing Address - Zip Code:75639-2454
Mailing Address - Country:US
Mailing Address - Phone:903-692-3724
Mailing Address - Fax:
Practice Address - Street 1:814 GILMER RD STE 1
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-3614
Practice Address - Country:US
Practice Address - Phone:903-692-3724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61185743101YM0800X
WALF61280351106H00000X, 106H00000X
TX204896106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
15394067OtherCAQH