Provider Demographics
NPI:1386911451
Name:SHORE, SHANNON GANTT (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GANTT
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 1:209 BARIUM SPRINGS DRIVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-6238
Mailing Address - Country:US
Mailing Address - Phone:704-873-1011
Mailing Address - Fax:
Practice Address - Street 1:209 BARIUM SPRINGS DRIVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-6238
Practice Address - Country:US
Practice Address - Phone:704-873-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical