MEDICARE: JULIE SHORTRIDGE MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	S-0008535	OH
2	101YP2500X	Professional Counselor	LPC003547	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	201559520	OTHER	GA	TID
2	201559520	OTHER		TID

General Provider Information

NPI Number	:	1609871631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE SHORTRIDGE MA, LPC

Provider Business Mailing Address
First Line	:	PO BOX 2927
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30028-6512
Country	:	US
Telephone Number	:	404-274-5209
Fax Number	:	770-818-5607

Provider Business Practice Location Address
First Line	:	5991 PARKWAY NORTH BLVD STE B4
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-1342
Country	:	US
Telephone Number	:	404-274-5209
Fax Number	:	770-818-5607

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	09/24/2018

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