Provider Demographics
NPI:1326807934
Name:SHORT, TELL JAMES
Entity Type:Individual
Prefix:
First Name:TELL
Middle Name:JAMES
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N STATE ST APT 306
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5080
Mailing Address - Country:US
Mailing Address - Phone:360-599-7979
Mailing Address - Fax:
Practice Address - Street 1:4201 MERIDIAN ST STE 113
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5532
Practice Address - Country:US
Practice Address - Phone:360-305-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61539982106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician