Provider Demographics
NPI:1033792601
Name:SHORT, RAYTWAN DARNELL
Entity Type:Individual
Prefix:
First Name:RAYTWAN
Middle Name:DARNELL
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 16TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-1502
Mailing Address - Country:US
Mailing Address - Phone:202-597-9526
Mailing Address - Fax:
Practice Address - Street 1:534 ATLANTIC ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3708
Practice Address - Country:US
Practice Address - Phone:202-248-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service