Provider Demographics
NPI:1699271510
Name:SHINE, TONDA NICHELLE
Entity type:Individual
Prefix:
First Name:TONDA
Middle Name:NICHELLE
Last Name:SHINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16308 EASTHAM CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3251
Mailing Address - Country:US
Mailing Address - Phone:215-668-5305
Mailing Address - Fax:
Practice Address - Street 1:13400 DILLE DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-9134
Practice Address - Country:US
Practice Address - Phone:301-952-7063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP4245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health