Provider Demographics
NPI:1194532366
Name:SHORTTT, MCKINNLEY ALEXUS
Entity type:Individual
Prefix:
First Name:MCKINNLEY
Middle Name:ALEXUS
Last Name:SHORTTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 WEXFORD MEADOWS LN APT G
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-0668
Mailing Address - Country:US
Mailing Address - Phone:843-291-4461
Mailing Address - Fax:
Practice Address - Street 1:1300 BAXTER ST STE AND455
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3053
Practice Address - Country:US
Practice Address - Phone:704-366-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician