Provider Demographics
NPI:1376658393
Name:SHORE, SYDNEY MARCIA (MFT)
Entity Type:Individual
Prefix:MS
First Name:SYDNEY
Middle Name:MARCIA
Last Name:SHORE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-1410
Mailing Address - Country:US
Mailing Address - Phone:209-368-2532
Mailing Address - Fax:209-365-6964
Practice Address - Street 1:18826 N LOWER SACRAMENTO RD
Practice Address - Street 2:SUITE C
Practice Address - City:WOODBRIDGE
Practice Address - State:CA
Practice Address - Zip Code:95258-9290
Practice Address - Country:US
Practice Address - Phone:209-368-2532
Practice Address - Fax:209-365-6964
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23707106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist