Provider Demographics
NPI:1114084787
Name:SHORE, SUSAN R (MSW LICSW BCD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:R
Last Name:SHORE
Suffix:
Gender:F
Credentials:MSW LICSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130A OLD ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02642-2102
Mailing Address - Country:US
Mailing Address - Phone:508-255-9313
Mailing Address - Fax:508-255-9313
Practice Address - Street 1:130A OLD ORCHARD RD
Practice Address - Street 2:
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642-2102
Practice Address - Country:US
Practice Address - Phone:508-255-9313
Practice Address - Fax:508-255-9313
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA1112481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
250971000OtherMAGELLAN
P07976OtherBLUE CROSS HMO
250971000OtherMAGELLAN