Provider Demographics
NPI:1609871631
Name:SHORTRIDGE, JULIE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:SHORTRIDGE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:BOBLENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, LSW
Mailing Address - Street 1:PO BOX 2927
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6512
Mailing Address - Country:US
Mailing Address - Phone:404-274-5209
Mailing Address - Fax:770-818-5607
Practice Address - Street 1:5991 PARKWAY NORTH BLVD STE B4
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-1342
Practice Address - Country:US
Practice Address - Phone:404-274-5209
Practice Address - Fax:770-818-5607
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS-00085351041C0700X
GALPC003547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA201559520OtherTID
201559520OtherTID