Provider Demographics
NPI:1457819138
Name:SHORES, KELLY (MA, LMFT, LAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHORES
Suffix:
Gender:F
Credentials:MA, LMFT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-1462
Mailing Address - Country:US
Mailing Address - Phone:317-710-7772
Mailing Address - Fax:
Practice Address - Street 1:415 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-1462
Practice Address - Country:US
Practice Address - Phone:317-710-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001781A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty