Provider Demographics
NPI:1184015349
Name:SHINE, STEPHANIE (CSAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SHINE
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 N TRYON ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-3408
Mailing Address - Country:US
Mailing Address - Phone:704-612-0566
Mailing Address - Fax:704-498-4846
Practice Address - Street 1:7925 N TRYON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3408
Practice Address - Country:US
Practice Address - Phone:704-612-0566
Practice Address - Fax:704-498-4846
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-20339101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)