Provider Demographics
NPI:1437569589
Name:SHORT, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
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 1:125 ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:PINE HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-6512
Mailing Address - Country:US
Mailing Address - Phone:856-669-8138
Mailing Address - Fax:
Practice Address - Street 1:2003 LINCOLN DR W STE C
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1529
Practice Address - Country:US
Practice Address - Phone:856-596-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)