Provider Demographics
NPI:1740689009
Name:SHORT, MARIESA
Entity type:Individual
Prefix:
First Name:MARIESA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 NW 62ND ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-2336
Mailing Address - Country:US
Mailing Address - Phone:814-746-1532
Mailing Address - Fax:
Practice Address - Street 1:1539 NW 62ND ST
Practice Address - Street 2:UNIT B
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-2336
Practice Address - Country:US
Practice Address - Phone:814-746-1532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst