Healthcare Provider Details

I. General information

NPI: 1538504246
Provider Name (Legal Business Name): JUSTIN JOSEPH SHORT L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUSTIN JOSEPH GONSETH

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 LAFAYETTE CENTER DR STE 1350
CHANTILLY VA
20151-1268
US

IV. Provider business mailing address

4229 LAFAYETTE CENTER DR STE 1350
CHANTILLY VA
20151-1268
US

V. Phone/Fax

Practice location:
  • Phone: 571-206-1577
  • Fax:
Mailing address:
  • Phone: 571-206-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0121000652
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: