Provider Demographics
NPI:1619576634
Name:SHORT, KAITLIN (MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 COLBY ST APT 2105
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2664
Mailing Address - Country:US
Mailing Address - Phone:972-439-5154
Mailing Address - Fax:
Practice Address - Street 1:2616 COLBY ST APT 2105
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2664
Practice Address - Country:US
Practice Address - Phone:972-439-5154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6397101YP2500X
631818101YP2500X
TX83856101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional