Provider Demographics
NPI:1104505072
Name:GORE, SALLIE
Entity type:Individual
Prefix:
First Name:SALLIE
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 DEEPWOODS RDG
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NC
Mailing Address - Zip Code:28457-7535
Mailing Address - Country:US
Mailing Address - Phone:910-899-2699
Mailing Address - Fax:
Practice Address - Street 1:5101 DUNLEA CT # 2101-C
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3448
Practice Address - Country:US
Practice Address - Phone:910-430-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician