Provider Demographics
NPI:1639568264
Name:SHORT, LINDSEY (ATC)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 WILLOW LAKE DR APT 205
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2678
Mailing Address - Country:US
Mailing Address - Phone:575-635-0853
Mailing Address - Fax:
Practice Address - Street 1:3411 WILLOW LAKE DR
Practice Address - Street 2:APT 205
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2614
Practice Address - Country:US
Practice Address - Phone:575-635-0853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
MI2601001582174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program