Provider Demographics
NPI:1497166102
Name:SHORE, COURTNEY (IMF)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SHORE
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 BALBOA BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1516
Mailing Address - Country:US
Mailing Address - Phone:818-600-2284
Mailing Address - Fax:
Practice Address - Street 1:5535 BALBOA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1516
Practice Address - Country:US
Practice Address - Phone:818-600-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF #80089106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist