Provider Demographics
NPI:1104875038
Name:SHINE, KATINA LYNNIECE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATINA
Middle Name:LYNNIECE
Last Name:SHINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE.
Mailing Address - Street 2:STE 1D03 WINN ARMY COMMUNITY HOSPITAL
Mailing Address - City:FT. STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-7016
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE.
Practice Address - Street 2:STE 1D03 WINN ARMY COMMUNITY HOSPITAL
Practice Address - City:FT. STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5674
Practice Address - Country:US
Practice Address - Phone:912-435-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003023867103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical