Basic Information
Provider Information | |||||||||
NPI: | 1164052890 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHORES | ||||||||
FirstName: | ALYSSA | ||||||||
MiddleName: | LAUREN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LATTA | ||||||||
OtherFirstName: | ALYSSA | ||||||||
OtherMiddleName: | LAUREN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1978 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218021978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107491015 | ||||||||
FaxNumber: | 4107490654 | ||||||||
Practice Location | |||||||||
Address1: | 1104 HEALTHWAY DR | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218044469 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102195483 | ||||||||
FaxNumber: | 4102195486 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2020 | ||||||||
LastUpdateDate: | 03/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 25059 | MD | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 25059 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 119591300 | 05 | MD |   | MEDICAID |