Provider Demographics
NPI:1629547120
Name:GORE, SHANNON (RBT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 SE 14TH CIR
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33035-2226
Mailing Address - Country:US
Mailing Address - Phone:850-603-7351
Mailing Address - Fax:
Practice Address - Street 1:10300 SUNSET DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3012
Practice Address - Country:US
Practice Address - Phone:305-508-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-16-22805106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician