Provider Demographics
NPI:1215490057
Name:SHINE SPEECH LANGUAGE THERAPY LLC
Entity type:Organization
Organization Name:SHINE SPEECH LANGUAGE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:770-337-5465
Mailing Address - Street 1:505 LAKELAND PLZ STE 343
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2807
Mailing Address - Country:US
Mailing Address - Phone:770-337-5465
Mailing Address - Fax:678-899-6333
Practice Address - Street 1:107 PILGRIM VILLAGE DR SUITE 400
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:770-337-5465
Practice Address - Fax:678-899-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP003981OtherSPEECH PATHOLOGY LICENSE