Provider Demographics
NPI:1124569157
Name:SHORELINE NEUROPSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:SHORELINE NEUROPSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:JAMIE
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:203-693-1510
Mailing Address - Street 1:6209 KNIGHTSGATE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0603
Mailing Address - Country:US
Mailing Address - Phone:203-693-1510
Mailing Address - Fax:938-253-3590
Practice Address - Street 1:204 CHERRY ST STE 15
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3555
Practice Address - Country:US
Practice Address - Phone:203-876-0545
Practice Address - Fax:938-253-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.004567363LP0808X
363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty