Provider Demographics
NPI:1255868626
Name:SHORE, BRIDGET ANITA (BCBA-D)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ANITA
Last Name:SHORE
Suffix:
Gender:F
Credentials:BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36227 E ELDORADO LAKE DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-9474
Mailing Address - Country:US
Mailing Address - Phone:941-357-6840
Mailing Address - Fax:352-602-4145
Practice Address - Street 1:2050 CLASSIQUE LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5787
Practice Address - Country:US
Practice Address - Phone:352-508-5243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-04-1993103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst