Provider Demographics
NPI:1063681401
Name:SHORT, KATIE ROSE
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ROSE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S SEMINOLE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-5520
Mailing Address - Country:US
Mailing Address - Phone:352-408-5572
Mailing Address - Fax:
Practice Address - Street 1:405 S SEMINOLE AVE
Practice Address - Street 2:
Practice Address - City:MINNEOLA
Practice Address - State:FL
Practice Address - Zip Code:34715-5520
Practice Address - Country:US
Practice Address - Phone:352-408-5572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 4431235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist