Healthcare Provider Details

I. General information

NPI: 1891708335
Provider Name (Legal Business Name): TIMOTHY C SHORT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 S APOLLO BLVD
MELBOURNE FL
32901-4407
US

IV. Provider business mailing address

1611 S APOLLO BLVD
MELBOURNE FL
32901-4407
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-2444
  • Fax: 321-952-4131
Mailing address:
  • Phone: 321-724-2444
  • Fax: 321-952-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPY4790
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: