Provider Demographics
NPI:1396583753
Name:SHORT, DARLENE M
Entity type:Individual
Prefix:
First Name:DARLENE
Middle Name:M
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0220
Mailing Address - Country:US
Mailing Address - Phone:304-933-3073
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 220
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0220
Practice Address - Country:US
Practice Address - Phone:304-933-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty