Provider Demographics
NPI:1023845096
Name:SHORE, THERESA (LCSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-4232
Mailing Address - Country:US
Mailing Address - Phone:815-756-0842
Mailing Address - Fax:
Practice Address - Street 1:321 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2148
Practice Address - Country:US
Practice Address - Phone:630-686-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490205501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical