Healthcare Provider Details

I. General information

NPI: 1861037145
Provider Name (Legal Business Name): SHANICE NICOLE SHORTS LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707B KALORAMA RD NW
WASHINGTON DC
20009-2623
US

IV. Provider business mailing address

5583 HARRINGTON FALLS LN UNIT 1279
ALEXANDRIA VA
22312-4004
US

V. Phone/Fax

Practice location:
  • Phone: 202-851-3671
  • Fax:
Mailing address:
  • Phone: 940-642-4712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLG50082715
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: