Provider Demographics
NPI:1174667331
Name:SHORE, LESLEY IRENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:IRENE
Last Name:SHORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-1211
Mailing Address - Country:US
Mailing Address - Phone:508-359-8056
Mailing Address - Fax:
Practice Address - Street 1:315 NORTH ST
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-1211
Practice Address - Country:US
Practice Address - Phone:508-359-8056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA378103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist