Provider Demographics
NPI:1013698612
Name:SHORT, LORRISSA (LSAA)
Entity type:Individual
Prefix:
First Name:LORRISSA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 SAFELITE BLVD NE APT 6216
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-9135
Mailing Address - Country:US
Mailing Address - Phone:505-484-0406
Mailing Address - Fax:
Practice Address - Street 1:12 UNSER BLVD SE STE C
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6300
Practice Address - Country:US
Practice Address - Phone:505-636-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0629101Y00000X, 101YA0400X
NM1311175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist