MEDICARE: SHINE A LIGHT FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1629765599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINE A LIGHT FOUNDATION

Provider Business Mailing Address
First Line	:	2330 HIGHLAND DR STE 205
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4810
Country	:	US
Telephone Number	:	702-863-4704
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 HIGHLAND DR STE 205
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4810
Country	:	US
Telephone Number	:	725-222-4654
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SUPERVISOR
Name	:	JIMMY DURBIN
Credential	:	LCSW
Telephone Number	:	702-883-4464

Provider Enumeration Date	:	04/20/2023
Last Update Date	:	04/20/2023

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Directions to “SHINE A LIGHT FOUNDATION ” Practice Location

Language	Start Address	Practice Location

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