Healthcare Provider Details

I. General information

NPI: 1710491246
Provider Name (Legal Business Name): DEVONTE SHORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 CARTER RD
LANEXA VA
23089-5725
US

IV. Provider business mailing address

1710 CARTER RD
LANEXA VA
23089-5725
US

V. Phone/Fax

Practice location:
  • Phone: 804-433-9801
  • Fax:
Mailing address:
  • Phone: 804-433-9801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015454
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: