Provider Demographics
NPI:1811329626
Name:SHORT, LAURA GRISSOM (LCSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GRISSOM
Last Name:SHORT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-1703
Mailing Address - Country:US
Mailing Address - Phone:919-943-6452
Mailing Address - Fax:
Practice Address - Street 1:2100 WESTLAKE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-5802
Practice Address - Country:US
Practice Address - Phone:206-858-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076351041C0700X
WA605091081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical