Provider Demographics
NPI:1710491246
Name:SHORT, DEVONTE
Entity Type:Individual
Prefix:
First Name:DEVONTE
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 1:9212 MINITREE GLEN LN
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-3450
Mailing Address - Country:US
Mailing Address - Phone:804-433-9801
Mailing Address - Fax:
Practice Address - Street 1:22001 FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44118-4819
Practice Address - Country:US
Practice Address - Phone:216-932-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health