MEDICARE: DJUAN DESHONGE SHORT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	44SC06129200	NJ
2	1041C0700X	Clinical Social Worker	CW020719	PA

General Provider Information

NPI Number	:	1013536556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DJUAN DESHONGE SHORT LCSW

Provider Business Mailing Address
First Line	:	104 S 20TH ST STE V30
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-4410
Country	:	US
Telephone Number	:	267-225-2630
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 S 20TH ST STE V30
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-4410
Country	:	US
Telephone Number	:	267-225-2630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	02/07/2025

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