Healthcare Provider Details

I. General information

NPI: 1497581508
Provider Name (Legal Business Name): SHINE TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/21/2024
Certification Date: 09/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3295 E REBEL LN
SAN TAN VALLEY AZ
85143-1705
US

IV. Provider business mailing address

3295 E REBEL LN
SAN TAN VALLEY AZ
85143-1705
US

V. Phone/Fax

Practice location:
  • Phone: 208-505-7176
  • Fax:
Mailing address:
  • Phone: 208-505-7176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: DAVID LAWLOR
Title or Position: CHAIRMAN
Credential:
Phone: 208-505-7176