Provider Demographics
NPI:1720122989
Name:GORE, SHELLY MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:GORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4327 N HERMITAGE AVE APT 1W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1126
Mailing Address - Country:US
Mailing Address - Phone:773-296-8247
Mailing Address - Fax:
Practice Address - Street 1:3040 N WILTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4424
Practice Address - Country:US
Practice Address - Phone:773-296-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical