Provider Demographics
NPI:1871331561
Name:SHORT, TIFFANY JO (BA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JO
Last Name:SHORT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 TALL TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-5746
Mailing Address - Country:US
Mailing Address - Phone:304-997-3442
Mailing Address - Fax:
Practice Address - Street 1:956 YATES AVE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1683
Practice Address - Country:US
Practice Address - Phone:304-290-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency