Provider Demographics
NPI:1710570106
Name:SHORTS, DONOVAN K
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:K
Last Name:SHORTS
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 1:13239 S RHODES AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60827-1341
Mailing Address - Country:US
Mailing Address - Phone:773-968-0646
Mailing Address - Fax:
Practice Address - Street 1:18501 MAPLE CREEK DR STE 200185
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-5122
Practice Address - Country:US
Practice Address - Phone:708-719-4288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-23-65139103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician