Provider Demographics
NPI:1750410288
Name:SHORT, ELIZABETH ANN (MCD, CCC SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:SHORT
Suffix:
Gender:F
Credentials:MCD, CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 W DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8340
Mailing Address - Country:US
Mailing Address - Phone:918-430-4062
Mailing Address - Fax:
Practice Address - Street 1:2209 W DETROIT ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3628
Practice Address - Country:US
Practice Address - Phone:918-615-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2413235Z00000X
OK3422235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158836721Medicaid