Healthcare Provider Details

I. General information

NPI: 1386911451
Provider Name (Legal Business Name): SHANNON GANTT SHORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

479 STAFFORD ESTATES DR
SALISBURY NC
28146-0515
US

IV. Provider business mailing address

479 STAFFORD ESTATES DR
SALISBURY NC
28146-0515
US

V. Phone/Fax

Practice location:
  • Phone: 704-677-9012
  • Fax:
Mailing address:
  • Phone: 704-677-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC007665
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC00002032
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC21651
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number904014279
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34010177A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: