MEDICARE: MATTHEW MERRITT SHORE MSW, LICSW

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	21474-LICSW	MN

General Provider Information

NPI Number	:	1730431131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW MERRITT SHORE MSW, LICSW

Provider Business Mailing Address
First Line	:	3001 HENNEPIN AVE
Second Line	:	#2170
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2647
Country	:	US
Telephone Number	:	612-825-3440
Fax Number	:	612-827-2477

Provider Business Practice Location Address
First Line	:	3001 HENNEPIN AVE
Second Line	:	#2170
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2647
Country	:	US
Telephone Number	:	612-825-3440
Fax Number	:	612-827-2477

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

Provider Enumeration Date	:	10/09/2012
Last Update Date	:	10/09/2012

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