Provider Demographics
NPI:1164101341
Name:SHORTER, KALEB SHERMAN
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:SHERMAN
Last Name:SHORTER
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 1:6628 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-7113
Mailing Address - Country:US
Mailing Address - Phone:318-658-0056
Mailing Address - Fax:
Practice Address - Street 1:6628 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-7113
Practice Address - Country:US
Practice Address - Phone:318-658-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator