Provider Demographics
NPI:1619739240
Name:SHINE YOUR LIGHT COUNSELING PLLC
Entity Type:Organization
Organization Name:SHINE YOUR LIGHT COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-202-2333
Mailing Address - Street 1:315 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:NC
Mailing Address - Zip Code:27505-9724
Mailing Address - Country:US
Mailing Address - Phone:336-202-2333
Mailing Address - Fax:
Practice Address - Street 1:2515 WATSON AVE STE 111
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-6173
Practice Address - Country:US
Practice Address - Phone:336-202-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty