Provider Demographics
NPI:1932333838
Name:SHORACK, MARY (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHORACK
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BARKLEY CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4543
Mailing Address - Country:US
Mailing Address - Phone:239-275-5566
Mailing Address - Fax:239-936-5521
Practice Address - Street 1:42 BARKLEY CIR STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4543
Practice Address - Country:US
Practice Address - Phone:239-275-5566
Practice Address - Fax:239-936-5521
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0001254106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist