Provider Demographics
NPI:1366581605
Name:SHORT, MISTY DONALEE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DONALEE
Last Name:SHORT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 HIDDEN FOREST DR APT 10H
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-3734
Mailing Address - Country:US
Mailing Address - Phone:206-399-1440
Mailing Address - Fax:
Practice Address - Street 1:14 E CASINO RD
Practice Address - Street 2:BUILDING C
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-2628
Practice Address - Country:US
Practice Address - Phone:425-513-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist