Provider Demographics
NPI:1891041133
Name:SHINE PEDIATRIC THERAPY
Entity type:Organization
Organization Name:SHINE PEDIATRIC THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-476-9730
Mailing Address - Street 1:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-1637
Mailing Address - Country:US
Mailing Address - Phone:615-382-0500
Mailing Address - Fax:615-382-0501
Practice Address - Street 1:514 S BROWN ST
Practice Address - Street 2:SUITE 600
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2937
Practice Address - Country:US
Practice Address - Phone:615-382-0500
Practice Address - Fax:615-382-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3432225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty