Provider Demographics
NPI:1184286379
Name:SHORT, MICHELLE LE (LMT, MMP, BCTMB)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LE
Last Name:SHORT
Suffix:
Gender:F
Credentials:LMT, MMP, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 TRIPLE HILLS RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-7432
Mailing Address - Country:US
Mailing Address - Phone:417-527-3404
Mailing Address - Fax:
Practice Address - Street 1:403 PERKINS ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-3945
Practice Address - Country:US
Practice Address - Phone:731-446-3051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004036561225700000X
TN0000013506225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty