Healthcare Provider Details

I. General information

NPI: 1952822587
Provider Name (Legal Business Name): SHINE WELLNESS CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N STARKWEATHER ALY FL 3
ROMEO MI
48065-4690
US

IV. Provider business mailing address

1 N STARKWEATHER ALY FL 3
ROMEO MI
48065-4690
US

V. Phone/Fax

Practice location:
  • Phone: 586-281-6815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801091649
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. NAOMI MARGARET BABA
Title or Position: OWNER
Credential: LMSW
Phone: 810-531-5333