Provider Demographics
NPI:1457632606
Name:SHINING STAR THERAPY LLC
Entity Type:Organization
Organization Name:SHINING STAR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGGS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:708-715-2555
Mailing Address - Street 1:8341 OLD TOWN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3335
Mailing Address - Country:US
Mailing Address - Phone:708-715-2555
Mailing Address - Fax:708-221-6638
Practice Address - Street 1:8341 OLD TOWN DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3335
Practice Address - Country:US
Practice Address - Phone:708-715-2555
Practice Address - Fax:708-221-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14821225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty