MEDICARE: SHANNON GANTT SHORE LCSW

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	1041C0700X	Clinical Social Worker	C007665	NC

General Provider Information

NPI Number	:	1386911451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON GANTT SHORE LCSW

Provider Business Mailing Address
First Line	:	209 BARIUM SPRINGS DRIVE
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28677-6238
Country	:	US
Telephone Number	:	704-873-1011
Fax Number	:

Provider Business Practice Location Address
First Line	:	209 BARIUM SPRINGS DRIVE
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28677-6238
Country	:	US
Telephone Number	:	704-873-1011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2011
Last Update Date	:	05/24/2012

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