Provider Demographics
NPI:1932459146
Name:SHORES, BENJAMIN P
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:P
Last Name:SHORES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44303-1413
Mailing Address - Country:US
Mailing Address - Phone:330-762-5425
Mailing Address - Fax:330-762-4019
Practice Address - Street 1:640 W MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44303-1413
Practice Address - Country:US
Practice Address - Phone:330-762-5425
Practice Address - Fax:330-762-4019
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI1201219104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI1201219OtherLICENSED INDEPENDENT SOCIAL WORKER