Provider Demographics
NPI:1801450234
Name:SHORE, EMILY (LCSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SHORE
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:PO BOX 1407
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1407
Mailing Address - Country:US
Mailing Address - Phone:801-518-4929
Mailing Address - Fax:
Practice Address - Street 1:1218 BOND AVE
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3503
Practice Address - Country:US
Practice Address - Phone:208-534-7881
Practice Address - Fax:208-242-4464
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
ID88617411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty