Provider Demographics
NPI:1679683130
Name:SHORE, AYNE (MFT)
Entity Type:Individual
Prefix:
First Name:AYNE
Middle Name:
Last Name:SHORE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1157
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95473-1157
Mailing Address - Country:US
Mailing Address - Phone:707-696-6978
Mailing Address - Fax:
Practice Address - Street 1:534 B ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5211
Practice Address - Country:US
Practice Address - Phone:707-696-6978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37449106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist