Provider Demographics
NPI:1316988553
Name:SHORT, PAUL EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWARD
Last Name:SHORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6024 CHARLES EDWARD TER
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5096
Mailing Address - Country:US
Mailing Address - Phone:240-856-9170
Mailing Address - Fax:
Practice Address - Street 1:9881 BROKENLAND PARKWAY #105
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046
Practice Address - Country:US
Practice Address - Phone:443-917-3102
Practice Address - Fax:240-892-0168
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04007103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD509SMedicare ID - Type Unspecified