Provider Demographics
NPI:1225243504
Name:SHORT, SUSANNE (NCPSYA)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:NCPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 FIFTH AVENUE
Mailing Address - Street 2:5C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:646-610-1920
Mailing Address - Fax:
Practice Address - Street 1:952 5TH AVE
Practice Address - Street 2:5C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1740
Practice Address - Country:US
Practice Address - Phone:646-610-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000629102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000629OtherSTATE PSYCHOANALYTIC LISE