Provider Demographics
NPI:1669670600
Name:SHORT, BOBBI LEE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:BOBBI
Middle Name:LEE
Last Name:SHORT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 CHASE CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2821
Mailing Address - Country:US
Mailing Address - Phone:410-419-9517
Mailing Address - Fax:
Practice Address - Street 1:11 W 3RD ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5330
Practice Address - Country:US
Practice Address - Phone:410-419-9517
Practice Address - Fax:800-725-4214
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2053101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4118146-00OtherMARYLAND MEDICAL ASSISTAN