Healthcare Provider Details

I. General information

NPI: 1649690363
Provider Name (Legal Business Name): CORRIE SHORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17201 SE 21ST ST
VANCOUVER WA
98683-3304
US

IV. Provider business mailing address

17201 SE 21ST ST
VANCOUVER WA
98683-3304
US

V. Phone/Fax

Practice location:
  • Phone: 360-907-5487
  • Fax:
Mailing address:
  • Phone: 360-907-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60536017
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61427204
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: