Provider Demographics
NPI:1053685131
Name:SHORT, KAREN SUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:SUE
Last Name:SHORT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14535 MILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-9447
Mailing Address - Country:US
Mailing Address - Phone:260-639-3629
Mailing Address - Fax:
Practice Address - Street 1:105 N 13TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1409
Practice Address - Country:US
Practice Address - Phone:260-724-2440
Practice Address - Fax:260-724-2402
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ05006582A225100000X
OHPT008652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist