Healthcare Provider Details

I. General information

NPI: 1407463524
Provider Name (Legal Business Name): ELIZABETH BROOKE SHORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 SENTRY PKWY E STE 200
BLUE BELL PA
19422-2319
US

IV. Provider business mailing address

450 SENTRY PKWY E STE 200
BLUE BELL PA
19422-2319
US

V. Phone/Fax

Practice location:
  • Phone: 267-802-1701
  • Fax:
Mailing address:
  • Phone: 267-802-1701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-68482
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: