Healthcare Provider Details

I. General information

NPI: 1871066019
Provider Name (Legal Business Name): SHINE COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 08/20/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 J N PEASE PL STE 104
CHARLOTTE NC
28262-4540
US

IV. Provider business mailing address

1931 J N PEASE PL STE 104
CHARLOTTE NC
28262-4540
US

V. Phone/Fax

Practice location:
  • Phone: 704-734-9480
  • Fax: 844-786-5796
Mailing address:
  • Phone: 704-548-1328
  • Fax: 844-786-5896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY PARKER
Title or Position: OWNER
Credential: LCSW
Phone: 704-548-1328