Provider Demographics
NPI:1447902317
Name:SHORE, MADELEINE
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:SHORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7046 CREBS AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4024
Mailing Address - Country:US
Mailing Address - Phone:615-415-0187
Mailing Address - Fax:
Practice Address - Street 1:11845 W OLYMPIC BLVD STE 1050W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5046
Practice Address - Country:US
Practice Address - Phone:424-330-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10986101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional