Provider Demographics
NPI:1356648034
Name:SHINING STAR LL
Entity Type:Organization
Organization Name:SHINING STAR LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-377-1849
Mailing Address - Street 1:3430 E JEFFERSON AVE
Mailing Address - Street 2:SUITE # 401
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4233
Mailing Address - Country:US
Mailing Address - Phone:313-377-1849
Mailing Address - Fax:313-557-2751
Practice Address - Street 1:533 MCDOUGALL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3912
Practice Address - Country:US
Practice Address - Phone:313-567-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness