Provider Demographics
NPI:1538317615
Name:SHAIN, COLLEEN (LCSW, BCD)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:
Last Name:SHAIN
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85055 CHERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3779
Mailing Address - Country:US
Mailing Address - Phone:502-552-8185
Mailing Address - Fax:912-882-3303
Practice Address - Street 1:102 LAKESHORE DR STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3875
Practice Address - Country:US
Practice Address - Phone:502-552-8185
Practice Address - Fax:912-882-3303
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW135341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical