Provider Demographics
NPI:1275695835
Name:SHORT, ANN (MS, OTRL)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 SHILLHAM CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-1541
Mailing Address - Country:US
Mailing Address - Phone:404-550-9476
Mailing Address - Fax:
Practice Address - Street 1:4420 SHILLHAM CT
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1541
Practice Address - Country:US
Practice Address - Phone:404-550-9476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3368225XP0200X
GAOT003970225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA368569697CMedicaid