Provider Demographics
NPI:1821203183
Name:SHORT, DARYL (DPT,MTC)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:SHORT
Suffix:
Gender:M
Credentials:DPT,MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-1105
Mailing Address - Country:US
Mailing Address - Phone:515-890-2787
Mailing Address - Fax:
Practice Address - Street 1:1212 5TH AVE N
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-1105
Practice Address - Country:US
Practice Address - Phone:515-890-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist