Provider Demographics
NPI:1164674677
Name:SHORT, GARY L (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:SHORT
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 COUNTY ROUTE 13
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-7904
Mailing Address - Country:US
Mailing Address - Phone:607-776-4151
Mailing Address - Fax:607-776-6929
Practice Address - Street 1:7634 CAMPBELL CREEK RD
Practice Address - Street 2:FAMILY LIFE MINISTRIES
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-7612
Practice Address - Country:US
Practice Address - Phone:607-776-4151
Practice Address - Fax:607-776-6929
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02539-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical