Provider Demographics
NPI:1659148484
Name:SHORTER, BRIANI ZYNETTE (LSW)
Entity Type:Individual
Prefix:MISS
First Name:BRIANI
Middle Name:ZYNETTE
Last Name:SHORTER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 W NORTH AVE STE 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-9755
Mailing Address - Country:US
Mailing Address - Phone:312-623-3260
Mailing Address - Fax:
Practice Address - Street 1:2302 W NORTH AVE STE 1E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-9755
Practice Address - Country:US
Practice Address - Phone:312-623-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107202103TC1900X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty