Provider Demographics
NPI:1730739582
Name:SHORT, MARY KATHERINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 E RIVERVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1122
Mailing Address - Country:US
Mailing Address - Phone:775-688-2422
Mailing Address - Fax:
Practice Address - Street 1:2655 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1666
Practice Address - Country:US
Practice Address - Phone:775-688-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI1213106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist