Healthcare Provider Details

I. General information

NPI: 1104096262
Provider Name (Legal Business Name): MS. MAIEKA S SHORT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W VICTORIA ST STE F&G
COMPTON CA
90220-5807
US

IV. Provider business mailing address

509 E. ROSCRANE AVENUE
COMPTON CA
90221
US

V. Phone/Fax

Practice location:
  • Phone: 310-669-9510
  • Fax: 310-669-9501
Mailing address:
  • Phone: 424-785-8661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number106242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: