Healthcare Provider Details

I. General information

NPI: 1154682771
Provider Name (Legal Business Name): ELIZABETH SHINE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W 14TH ST STE 200
WASHINGTON MO
63090-4198
US

IV. Provider business mailing address

901 W 14TH ST STE 200
WASHINGTON MO
63090-4198
US

V. Phone/Fax

Practice location:
  • Phone: 636-432-1992
  • Fax:
Mailing address:
  • Phone: 636-432-1992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2013042656
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: