Healthcare Provider Details

I. General information

NPI: 1558086967
Provider Name (Legal Business Name): SSHORT COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17482 HIGHWAY 4
JEMEZ SPRINGS NM
87025
US

IV. Provider business mailing address

PO BOX 573
JEMEZ SPRINGS NM
87025-0573
US

V. Phone/Fax

Practice location:
  • Phone: 612-505-2694
  • Fax:
Mailing address:
  • Phone: 612-505-2694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SUSANNE ANNETTE SHORT
Title or Position: SOLE OWNER
Credential: MSW, LICSW, LISC
Phone: 612-505-2694