Provider Demographics
NPI:1891009866
Name:SHORT, TRACY ANNE (PCC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANNE
Last Name:SHORT
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 CRESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-2209
Mailing Address - Country:US
Mailing Address - Phone:614-264-0601
Mailing Address - Fax:
Practice Address - Street 1:2700 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209-2536
Practice Address - Country:US
Practice Address - Phone:614-235-8832
Practice Address - Fax:614-235-8864
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH051023101YA0400X
OHC.0500234101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health