Provider Demographics
NPI:1487034708
Name:SHORTER-KING, MARY ANNA (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNA
Last Name:SHORTER-KING
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANNA
Other - Last Name:SHORTER-CASTANEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1191 CANON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9163
Mailing Address - Country:US
Mailing Address - Phone:719-276-2550
Mailing Address - Fax:
Practice Address - Street 1:1191 CANON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9163
Practice Address - Country:US
Practice Address - Phone:719-276-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
COCSW.099288291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker