Provider Demographics
NPI:1891708335
Name:SHORT, TIMOTHY C (PHD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:SHORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S APOLLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4407
Mailing Address - Country:US
Mailing Address - Phone:321-724-2444
Mailing Address - Fax:321-952-4131
Practice Address - Street 1:1611 S APOLLO BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4407
Practice Address - Country:US
Practice Address - Phone:321-724-2444
Practice Address - Fax:321-952-4131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4790103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59348Medicare PIN