Provider Demographics
NPI:1467107276
Name:SHORTER, SHAVONNE
Entity Type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:
Last Name:SHORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 WILLIAMS WAY BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-3641
Mailing Address - Country:US
Mailing Address - Phone:832-371-6748
Mailing Address - Fax:
Practice Address - Street 1:1803 WILLIAMS WAY BLVD STE 600
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-3641
Practice Address - Country:US
Practice Address - Phone:832-371-6748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-34027106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician