Provider Demographics
NPI:1639349020
Name:SHORT, SUSANNE ANNETTE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:ANNETTE
Last Name:SHORT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 573
Mailing Address - Street 2:
Mailing Address - City:JEMEZ SPRINGS
Mailing Address - State:NM
Mailing Address - Zip Code:87025-0573
Mailing Address - Country:US
Mailing Address - Phone:612-505-2694
Mailing Address - Fax:
Practice Address - Street 1:17482 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:JEMEZ SPRINGS
Practice Address - State:NM
Practice Address - Zip Code:87025-8702
Practice Address - Country:US
Practice Address - Phone:612-505-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099283741041C0700X
MN145431041C0700X
NM2022-00841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical