Basic Information
| Provider Information | |||||||||
| NPI: | 1417069162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHORES | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | M.A., CDC-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5808 CORDOVA ST | ||||||||
| Address2: | APT. #2 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995181355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075631000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 733 3RD | ||||||||
| Address2: | FERGUSON BUILDING | ||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427640 | ||||||||
| FaxNumber: | 9074427749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.