MEDICARE: SHORE PSYCHOLOGY, LLC

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	251S00000X	Community/Behavioral Health Agency
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1407493828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORE PSYCHOLOGY, LLC

Provider Business Mailing Address
First Line	:	112 SAINT CLAIRE PL STE 202
Second Line	:
City	:	STEVENSVILLE
State	:	MD
Zip	:	21666-2193
Country	:	US
Telephone Number	:	443-249-3162
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 SAINT CLAIRE PL STE 202
Second Line	:
City	:	STEVENSVILLE
State	:	MD
Zip	:	21666-2193
Country	:	US
Telephone Number	:	443-249-3162
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	LAURIE REIDER LEWIS
Credential	:	PSYD
Telephone Number	:	443-249-3162

Provider Enumeration Date	:	12/04/2019
Last Update Date	:	12/04/2019

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