Provider Demographics
NPI:1932964343
Name:SHORT, KORI (LLPC)
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5036 PARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2804
Mailing Address - Country:US
Mailing Address - Phone:248-410-8469
Mailing Address - Fax:
Practice Address - Street 1:12319 HIGHLAND RD STE 401
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2946
Practice Address - Country:US
Practice Address - Phone:810-475-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional