Provider Demographics
NPI:1881790368
Name:SHORT, CAROLYN R
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:R
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:S57W25446 LOIS LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9605
Mailing Address - Country:US
Mailing Address - Phone:262-542-4842
Mailing Address - Fax:
Practice Address - Street 1:741 N GRAND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4820
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI702-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39225600Medicaid