MEDICARE: SHINE THERAPY 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1720668148
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINE THERAPY PLLC

Provider Business Mailing Address
First Line	:	1711 CARLTON AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5439
Country	:	US
Telephone Number	:	231-590-3297
Fax Number	:	517-323-9531

Provider Business Practice Location Address
First Line	:	1444 MICHIGAN ST NE STE 7
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2028
Country	:	US
Telephone Number	:	616-259-4548
Fax Number	:

Authorized Official
Title or Position	:	MANGER
Name	:	CATHY GALLEGOS
Credential	:
Telephone Number	:	517-483-2461

Provider Enumeration Date	:	04/09/2021
Last Update Date	:	04/09/2021

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