Healthcare Provider Details

I. General information

NPI: 1871126631
Provider Name (Legal Business Name): LAUREL LYNNE SHORT MED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 CHAMBERLAIN PL STE 100
WEBSTER GROVES MO
63119-2782
US

IV. Provider business mailing address

739 CLARK AVE
WEBSTER GROVES MO
63119-1912
US

V. Phone/Fax

Practice location:
  • Phone: 314-834-0655
  • Fax:
Mailing address:
  • Phone: 314-606-7552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2016035429
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2016035429
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: