Basic Information
| Provider Information | |||||||||
| NPI: | 1821695313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | SHERRIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012494218 | ||||||||
| FaxNumber: | 6012494234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012494218 | ||||||||
| FaxNumber: | 6012494234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 553 | MS | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.