Provider Demographics
NPI:1629692595
Name:SHORT, KAROL
Entity Type:Individual
Prefix:
First Name:KAROL
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SABLE CHASE BLVD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3456
Mailing Address - Country:US
Mailing Address - Phone:706-975-6057
Mailing Address - Fax:
Practice Address - Street 1:101 SABLE CHASE BLVD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3456
Practice Address - Country:US
Practice Address - Phone:706-975-6057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service