Provider Demographics
NPI:1982300778
Name:SHORT, NICOLE (DP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:DP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49713-9268
Mailing Address - Country:US
Mailing Address - Phone:231-535-2822
Mailing Address - Fax:231-535-2376
Practice Address - Street 1:1619 W M 32
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9287
Practice Address - Country:US
Practice Address - Phone:231-535-2822
Practice Address - Fax:231-535-2376
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)