Basic Information
| Provider Information | |||||||||
| NPI: | 1639553357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHINING STAR COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4580 S EASTERN AVE STE 33 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891196100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028827827 | ||||||||
| FaxNumber: | 7025229336 | ||||||||
| Practice Location | |||||||||
| Address1: | 5420 W SAHARA AVE | ||||||||
| Address2: | #101 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891460394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028827827 | ||||||||
| FaxNumber: | 7025229336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2015 | ||||||||
| LastUpdateDate: | 09/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7028827827 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.