Provider Demographics
NPI:1619197399
Name:SHORES, MISTY D (AUD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:SHORES
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N WASHINGTON ST STE 209
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2260
Mailing Address - Country:US
Mailing Address - Phone:509-484-8069
Mailing Address - Fax:509-462-4086
Practice Address - Street 1:5628 N DIVISION ST STE D1
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1268
Practice Address - Country:US
Practice Address - Phone:509-484-8069
Practice Address - Fax:509-462-4086
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00003521231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8377079Medicaid