Provider Demographics
NPI:1659769875
Name:SHORTER, ANTUAN
Entity Type:Individual
Prefix:
First Name:ANTUAN
Middle Name:
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 1:565 PEACHTREE ST NE # 30308
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 S ZACK HINTON PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3335
Practice Address - Country:US
Practice Address - Phone:404-931-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health