Provider Demographics
NPI:1558146407
Name:SHORT, MIRANDA L (LAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 FRANKLIN CORNER RD APT C6
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2507
Mailing Address - Country:US
Mailing Address - Phone:606-733-5795
Mailing Address - Fax:
Practice Address - Street 1:3535 QUAKERBRIDGE RD STE 300
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-1200
Practice Address - Country:US
Practice Address - Phone:609-249-4641
Practice Address - Fax:609-488-4930
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00733500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health