Healthcare Provider Details

I. General information

NPI: 1346703964
Provider Name (Legal Business Name): MALLORY SHORT MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MALLORY HALL

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 03/23/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 PARK DR
STURGEON BAY WI
54235-2325
US

IV. Provider business mailing address

624 N 3RD AVE
STURGEON BAY WI
54235-2325
US

V. Phone/Fax

Practice location:
  • Phone: 920-255-8068
  • Fax:
Mailing address:
  • Phone: 920-255-8068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5858-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5858-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: