Provider Demographics
NPI:1497843163
Name:SHORT, ANDREW (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SHORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PROVIDENCE RD
Mailing Address - Street 2:STE 2
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2206
Mailing Address - Country:US
Mailing Address - Phone:919-493-3376
Mailing Address - Fax:
Practice Address - Street 1:180 PROVIDENCE RD
Practice Address - Street 2:STE 2
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2206
Practice Address - Country:US
Practice Address - Phone:919-493-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0911103TC0700X
NC911103TC2200X, 103TB0200X, 103T00000X, 103TF0000X, 103TM1800X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000132Medicaid