Provider Demographics
NPI:1871154641
Name:MARILYN SHORE, PHD, INC.
Entity type:Organization
Organization Name:MARILYN SHORE, PHD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-494-1484
Mailing Address - Street 1:2659 TOWNSGATE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2776
Mailing Address - Country:US
Mailing Address - Phone:805-494-1484
Mailing Address - Fax:805-494-9677
Practice Address - Street 1:2659 TOWNSGATE RD STE 201
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2776
Practice Address - Country:US
Practice Address - Phone:805-494-1484
Practice Address - Fax:805-494-9677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY118866OtherPSYCHOLOGIST