Provider Demographics
NPI:1407253123
Name:SHINE, WILLIE (CSAC)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:SHINE
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:MR
Other - First Name:WILLIE
Other - Middle Name:
Other - Last Name:SHINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSAC
Mailing Address - Street 1:7925 N TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-3408
Mailing Address - Country:US
Mailing Address - Phone:980-612-0566
Mailing Address - Fax:704-498-4846
Practice Address - Street 1:7925 NORTH TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-612-0566
Practice Address - Fax:704-498-4846
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-20389101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)