Provider Demographics
NPI:1225640485
Name:HINES, SHANITTA D
Entity Type:Individual
Prefix:
First Name:SHANITTA
Middle Name:D
Last Name:HINES
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 1:9331 BLUE GRASS DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-4449
Mailing Address - Country:US
Mailing Address - Phone:707-712-1060
Mailing Address - Fax:
Practice Address - Street 1:VICTOR COMMUNITY SUPPORT SERVICES
Practice Address - Street 2:
Practice Address - City:302 CHERRY LANE
Practice Address - State:CA
Practice Address - Zip Code:95337
Practice Address - Country:US
Practice Address - Phone:209-647-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health