Provider Demographics
NPI:1073393195
Name:SHORT, MAKENZI (RBT)
Entity Type:Individual
Prefix:
First Name:MAKENZI
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 CASON ST # 2
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2843
Mailing Address - Country:US
Mailing Address - Phone:765-446-4185
Mailing Address - Fax:765-448-1864
Practice Address - Street 1:5750 FALLS DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7147
Practice Address - Country:US
Practice Address - Phone:260-702-9898
Practice Address - Fax:765-448-1864
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-284199106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician