Provider Demographics
NPI:1578251765
Name:SHORT, AMY LOUISE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:SHORT
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8559
Mailing Address - Country:US
Mailing Address - Phone:309-825-5180
Mailing Address - Fax:
Practice Address - Street 1:405 W SUPERIOR ST STE 422
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-8561
Practice Address - Country:US
Practice Address - Phone:309-825-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027113363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health