Provider Demographics
NPI:1417203019
Name:SHORT, MONIQUE
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 NW 52ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-6007
Mailing Address - Country:US
Mailing Address - Phone:405-706-4996
Mailing Address - Fax:
Practice Address - Street 1:2828 NW 57TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6814
Practice Address - Country:US
Practice Address - Phone:405-840-1234
Practice Address - Fax:405-840-1211
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator