Provider Demographics
NPI:1194568568
Name:SHORT, FAVIAN S
Entity type:Individual
Prefix:
First Name:FAVIAN
Middle Name:S
Last Name:SHORT
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 1:2910 WELLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-4899
Mailing Address - Country:US
Mailing Address - Phone:615-796-3951
Mailing Address - Fax:
Practice Address - Street 1:2910 WELLINGTON PL
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-4899
Practice Address - Country:US
Practice Address - Phone:615-796-3951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)