Provider Demographics
NPI:1275833543
Name:SHINE, STACEY CHRISTINA
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:CHRISTINA
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 1:125 COOL SPRINGS BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6574
Mailing Address - Country:US
Mailing Address - Phone:901-258-3895
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:125 COOL SPRINGS BLVD STE 270
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-6574
Practice Address - Country:US
Practice Address - Phone:901-258-3895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TN5019101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator