Provider Demographics
NPI:1861616179
Name:SHORT, DAVIS TAYLOR (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:DAVIS
Middle Name:TAYLOR
Last Name:SHORT
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:143 N BOHEMIA AVE.
Practice Address - Street 2:
Practice Address - City:CECILTON
Practice Address - State:MD
Practice Address - Zip Code:21913-0488
Practice Address - Country:US
Practice Address - Phone:410-458-2537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD032681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid