Healthcare Provider Details

I. General information

NPI: 1043007586
Provider Name (Legal Business Name): KESIA ELISE SHINE ND, MBA, BSHA/IS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15781 WILDEMERE ST
DETROIT MI
48238-1439
US

IV. Provider business mailing address

15781 WILDEMERE ST
DETROIT MI
48238-1439
US

V. Phone/Fax

Practice location:
  • Phone: 602-460-7635
  • Fax:
Mailing address:
  • Phone: 602-460-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code174V00000X
TaxonomyClinical Ethicist
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: