Provider Demographics
NPI:1093973315
Name:SHORT, CANDICE LEE (OTA/L)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LEE
Last Name:SHORT
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5300
Mailing Address - Country:US
Mailing Address - Phone:406-761-4300
Mailing Address - Fax:406-761-8883
Practice Address - Street 1:1500 32ND ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5300
Practice Address - Country:US
Practice Address - Phone:406-761-4300
Practice Address - Fax:406-761-8883
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT776224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant