Provider Demographics
NPI:1134247604
Name:SHORT, PATRICIA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:MARIE
Last Name:SHORT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 STATE AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4065
Mailing Address - Country:US
Mailing Address - Phone:360-709-3400
Mailing Address - Fax:360-956-1234
Practice Address - Street 1:1026 STATE AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4065
Practice Address - Country:US
Practice Address - Phone:360-709-3400
Practice Address - Fax:360-956-1234
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2537103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB32736Medicare ID - Type Unspecified