Provider Demographics
NPI:1639789563
Name:SHORES, DESIRE C
Entity Type:Individual
Prefix:
First Name:DESIRE
Middle Name:C
Last Name:SHORES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESIRE
Other - Middle Name:C
Other - Last Name:MOTZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8140
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0187
Practice Address - Street 1:2700 SIMPSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4335
Practice Address - Country:US
Practice Address - Phone:360-612-0012
Practice Address - Fax:360-577-0187
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61090379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health