Provider Demographics
NPI:1013536556
Name:SHORT, DJUAN DESHONGE (LCSW)
Entity Type:Individual
Prefix:
First Name:DJUAN
Middle Name:DESHONGE
Last Name:SHORT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5662 BELMAR TER APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-4713
Mailing Address - Country:US
Mailing Address - Phone:240-602-9929
Mailing Address - Fax:
Practice Address - Street 1:2 LOGAN SQ STE 300
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-2733
Practice Address - Country:US
Practice Address - Phone:267-225-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0207191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical