Provider Demographics
NPI:1932326840
Name:SHORE, ROBERT JERALD (PHD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JERALD
Last Name:SHORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SPRING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3537
Mailing Address - Country:US
Mailing Address - Phone:903-939-8760
Mailing Address - Fax:903-939-8760
Practice Address - Street 1:804 SPRING CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3537
Practice Address - Country:US
Practice Address - Phone:903-939-8760
Practice Address - Fax:903-939-8760
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24292103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11601-160-01Medicaid