Provider Demographics
NPI:1679876163
Name:SHORE, ELENA D (LCSW)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:D
Last Name:SHORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:
Other - Last Name:SHORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 732
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-0732
Mailing Address - Country:US
Mailing Address - Phone:541-870-1122
Mailing Address - Fax:
Practice Address - Street 1:285 E OREGON AVE
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-9160
Practice Address - Country:US
Practice Address - Phone:541-870-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL57721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019047Medicaid