=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033611520
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHINE COUNSELING AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2018
-----------------------------------------------------
Last Update Date | 03/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 WASHINGTON ST STE C17
-----------------------------------------------------
City | NORWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02061-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-427-6146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 WASHINGTON ST STE C17
-----------------------------------------------------
City | NORWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02061-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-427-6146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | RENEE REILLY GAMBELL
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 781-427-6146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 118888
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------