Provider Demographics
NPI:1700572500
Name:SHORTER, MICHAEL JEROME (LGPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
Last Name:SHORTER
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12104 CHESTERTON DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1608
Mailing Address - Country:US
Mailing Address - Phone:202-487-7928
Mailing Address - Fax:
Practice Address - Street 1:12104 CHESTERTON DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-1608
Practice Address - Country:US
Practice Address - Phone:202-487-7928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional