Provider Demographics
NPI:1720469349
Name:SHORT, OCTAZIA (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:OCTAZIA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5029
Mailing Address - Country:US
Mailing Address - Phone:252-321-8080
Mailing Address - Fax:252-321-7999
Practice Address - Street 1:231 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5029
Practice Address - Country:US
Practice Address - Phone:252-321-8080
Practice Address - Fax:252-321-7999
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0095101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical