Provider Demographics
NPI:1730431131
Name:SHORE, MATTHEW MERRITT (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MERRITT
Last Name:SHORE
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 HENNEPIN AVE
Mailing Address - Street 2:#2170
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2647
Mailing Address - Country:US
Mailing Address - Phone:612-825-3440
Mailing Address - Fax:612-827-2477
Practice Address - Street 1:3001 HENNEPIN AVE
Practice Address - Street 2:#2170
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2647
Practice Address - Country:US
Practice Address - Phone:612-825-3440
Practice Address - Fax:612-827-2477
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21474-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical