Provider Demographics
NPI:1942312871
Name:SHORT, PENNY LORIE (OTRL)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:LORIE
Last Name:SHORT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 HARTZOGE LN
Mailing Address - Street 2:
Mailing Address - City:MAIDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28650-8342
Mailing Address - Country:US
Mailing Address - Phone:704-736-5279
Mailing Address - Fax:828-428-9502
Practice Address - Street 1:240 HARTZOGE LN
Practice Address - Street 2:
Practice Address - City:MAIDEN
Practice Address - State:NC
Practice Address - Zip Code:28650-8342
Practice Address - Country:US
Practice Address - Phone:704-736-5279
Practice Address - Fax:828-428-9502
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6028225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1697Medicaid
NC721634Medicaid
NC721634Medicaid