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General NPI Number Information
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NPI Number | 1578080412
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Entity Type | Organization
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Legal Business Name | SHINE INTEGRATIVE THERAPY, LLC
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1103 N MAIN ST
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City | NEWTON
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State | KS
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Zip | 67114-1837
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Country | US
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Telephone | 316-803-1011
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Fax | 316-803-1754
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Provider Business Mailing Address
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Address Line | 1103 N MAIN ST
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City | NEWTON
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State | KS
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Zip | 67114-1837
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Country | US
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Telephone | 316-993-6449
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Fax | 316-803-1754
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Authorized Official
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Title or Position | OWNER
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Name | TRACY SMITH
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Credential | LCMFT
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Telephone | 316-803-1011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 2885
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License Number State | KS
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