Provider Demographics
NPI:1275645038
Name:SHORE, DOUGLAS L (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:SHORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36405 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2957
Mailing Address - Country:US
Mailing Address - Phone:586-791-6060
Mailing Address - Fax:586-791-8211
Practice Address - Street 1:36405 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2957
Practice Address - Country:US
Practice Address - Phone:586-791-6060
Practice Address - Fax:586-791-8211
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF 34697762Medicare ID - Type Unspecified
MIS48545Medicare UPIN