MEDICARE: SHORE THERAPY CENTER FOR WELLNESS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1285385617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORE THERAPY CENTER FOR WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	1006 MARION AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-5130
Country	:	US
Telephone Number	:	630-362-0129
Fax Number	:

Provider Business Practice Location Address
First Line	:	1189 WILMETTE AVE # 174
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-2719
Country	:	US
Telephone Number	:	847-558-1546
Fax Number	:	847-787-1868

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CORRIE A. GOLDBERG
Credential	:	PH.D.
Telephone Number	:	847-558-1546

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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