MEDICARE: MR. KENNETH LOUIS 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	C003006	NC

General Provider Information

NPI Number	:	1871762641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH LOUIS SHORE LCSW

Provider Business Mailing Address
First Line	:	25 BLACKSTONE VALLEY PLACE
Second Line	:	SUITE 300 FELLOWSHIP HEALTH RESOURCES INC
City	:	LINCOLN
State	:	RI
Zip	:	02865-1163
Country	:	US
Telephone Number	:	401-333-3980
Fax Number	:	401-333-3980

Provider Business Practice Location Address
First Line	:	4112 BLUE RIDGE ROAD
Second Line	:	2ND FLOOR
City	:	RALEIGH
State	:	NC
Zip	:	27612-4652
Country	:	US
Telephone Number	:	919-573-6520
Fax Number	:	919-573-6557

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

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	02/26/2008

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