Provider Demographics
NPI:1821566365
Name:SHORT, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
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 1:5151 BONNEY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4384
Mailing Address - Country:US
Mailing Address - Phone:757-222-1315
Mailing Address - Fax:
Practice Address - Street 1:5151 BONNEY RD STE 107
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4384
Practice Address - Country:US
Practice Address - Phone:757-222-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician