Provider Demographics
NPI:1679909220
Name:SHORT, JAMES GLENN (LPC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:GLENN
Last Name:SHORT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6370 YELTON RD
Mailing Address - Street 2:
Mailing Address - City:APPLING
Mailing Address - State:GA
Mailing Address - Zip Code:30802-2901
Mailing Address - Country:US
Mailing Address - Phone:706-541-9382
Mailing Address - Fax:
Practice Address - Street 1:1285 MARKS CHURCH RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6329
Practice Address - Country:US
Practice Address - Phone:706-738-0443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006264101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional