MEDICARE: SHINING BRIGHT WELLNESS PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1700536299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING BRIGHT WELLNESS PLLC

Provider Business Mailing Address
First Line	:	1502 S PRAIRIE AVE UNIT H
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-3350
Country	:	US
Telephone Number	:	815-751-6439
Fax Number	:

Provider Business Practice Location Address
First Line	:	3547 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-3945
Country	:	US
Telephone Number	:	815-751-6439
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAWNA JOHNSON
Credential	:	LCSW
Telephone Number	:	815-751-6439

Provider Enumeration Date	:	03/27/2022
Last Update Date	:	03/27/2022

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