Healthcare Provider Details

I. General information

NPI: 1639349020
Provider Name (Legal Business Name): SUSANNE ANNETTE SHORT LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17482 HIGHWAY 4
JEMEZ SPRINGS NM
87025-8702
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 TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09928374
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14543
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022-0084
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: