Provider Demographics
NPI:1598844847
Name:SHORE, MARILYN A (PHD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:A
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 1:2659 TOWNSGATE ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361
Mailing Address - Country:US
Mailing Address - Phone:805-494-1484
Mailing Address - Fax:805-494-9677
Practice Address - Street 1:2659 TOWNSGATE ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:805-494-1484
Practice Address - Fax:805-494-9677
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPS411866103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP11866Medicare ID - Type Unspecified
R27451Medicare UPIN