Provider Demographics
NPI:1881268530
Name:SHORE, SAMARA
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:SHORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-1010
Mailing Address - Country:US
Mailing Address - Phone:714-916-2559
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN STE 200
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2349
Practice Address - Country:US
Practice Address - Phone:916-382-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1815103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst