Basic Information
| Provider Information | |||||||||
| NPI: | 1194217794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | ALYSSA | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 GRANGE AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430501113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023706920 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675603582 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | S.1600512 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.