Healthcare Provider Details

I. General information

NPI: 1376931501
Provider Name (Legal Business Name): STACI SHORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 BELLE TERRE BLVD
LA PLACE LA
70068-1715
US

IV. Provider business mailing address

1769 BOULEVARD DE PROVINCE APT E
BATON ROUGE LA
70816-8618
US

V. Phone/Fax

Practice location:
  • Phone: 504-493-2271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT 1096
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC3219
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberMFT 1096
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFT 1096
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMFT 1096
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: