Basic Information
| Provider Information | |||||||||
| NPI: | 1720668148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHINE THERAPY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 CARLTON AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315903297 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Practice Location | |||||||||
| Address1: | 1444 MICHIGAN ST NE STE 7 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162594548 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | GALLEGOS | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANGER | ||||||||
| AuthorizedOfficialTelephone: | 5174832461 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.