Provider Demographics
NPI:1790554699
Name:SHORE, MARY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:SHORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 TOPSIDE RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-6056
Mailing Address - Country:US
Mailing Address - Phone:865-773-7582
Mailing Address - Fax:
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:185-583-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician