Provider Demographics
NPI:1164544284
Name:SHORE, ANNETTE URBAN (MA)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:URBAN
Last Name:SHORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 SW KELLY AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4630
Mailing Address - Country:US
Mailing Address - Phone:503-222-1807
Mailing Address - Fax:503-220-5041
Practice Address - Street 1:3434 SW KELLY AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4630
Practice Address - Country:US
Practice Address - Phone:503-222-1807
Practice Address - Fax:503-220-5041
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health