Healthcare Provider Details

I. General information

NPI: 1932843109
Provider Name (Legal Business Name): SHINE-PEDIATRIC THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4565 COMMERCIAL DR STE 105
NICEVILLE FL
32578-8856
US

IV. Provider business mailing address

4565 COMMERCIAL DR STE 105
NICEVILLE FL
32578-8856
US

V. Phone/Fax

Practice location:
  • Phone: 850-353-2415
  • Fax: 850-353-2528
Mailing address:
  • Phone: 850-353-2415
  • Fax: 850-353-2528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY A BRYCE-TRAVIS
Title or Position: OWNER
Credential: MOT/L
Phone: 850-353-2415