Provider Demographics
NPI:1619124716
Name:SHORES, BRENDA (LICSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SHORES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE N 464
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2801
Mailing Address - Country:US
Mailing Address - Phone:651-659-2900
Mailing Address - Fax:651-645-7307
Practice Address - Street 1:1821 UNIVERSITY AVE W
Practice Address - Street 2:SUITE N 464
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:651-659-2900
Practice Address - Fax:651-645-7307
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12470OtherLICSW