MEDICARE: MS. SUSANNE ANNETTE SHORT LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	09928374	CO
2	1041C0700X	Clinical Social Worker	14543	MN
3	1041C0700X	Clinical Social Worker	2022-0084	NM

General Provider Information

NPI Number	:	1639349020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSANNE ANNETTE SHORT LICSW

Provider Business Mailing Address
First Line	:	PO BOX 573
Second Line	:
City	:	JEMEZ SPRINGS
State	:	NM
Zip	:	87025-0573
Country	:	US
Telephone Number	:	612-505-2694
Fax Number	:

Provider Business Practice Location Address
First Line	:	17482 HIGHWAY 4
Second Line	:
City	:	JEMEZ SPRINGS
State	:	NM
Zip	:	87025-8702
Country	:	US
Telephone Number	:	612-505-2694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	10/03/2022

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