Provider Demographics
NPI:1669826509
Name:SHORT, JUSTIN KYLE (CDCA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:KYLE
Last Name:SHORT
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WEST TECHNE DR. SUITE B-5
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150
Mailing Address - Country:US
Mailing Address - Phone:513-753-9964
Mailing Address - Fax:513-753-9968
Practice Address - Street 1:50 WEST TECHNE DR. SUITE B-5
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150
Practice Address - Country:US
Practice Address - Phone:513-753-9964
Practice Address - Fax:513-753-9968
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150465101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)