Provider Demographics
NPI:1346703964
Name:SHORT, MALLORY (MS)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:624 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2325
Mailing Address - Country:US
Mailing Address - Phone:920-255-8068
Mailing Address - Fax:
Practice Address - Street 1:3320 PARK DR
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2325
Practice Address - Country:US
Practice Address - Phone:920-255-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5858-125101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional