Provider Demographics
NPI:1225336415
Name:SHORTY, GERALD (LMHC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:SHORTY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 ANDREA DR. SUITE 4 BUILDING E
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-269-5121
Mailing Address - Fax:
Practice Address - Street 1:851 ANDREA DR STE 4
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6726
Practice Address - Country:US
Practice Address - Phone:505-269-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0112581101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health