Provider Demographics
NPI:1316589666
Name:SHORT, LATANYA (CDCA)
Entity Type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1711
Mailing Address - Country:US
Mailing Address - Phone:513-751-7747
Mailing Address - Fax:
Practice Address - Street 1:4531 READING RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-1229
Practice Address - Country:US
Practice Address - Phone:513-751-8600
Practice Address - Fax:513-381-5959
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174823171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0376987Medicaid