Provider Demographics
NPI:1639553944
Name:SHINE FITNESS LLC
Entity Type:Organization
Organization Name:SHINE FITNESS LLC
Other - Org Name:SHINE INTEGRATED THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:3034-552-4019
Mailing Address - Street 1:2820 WOLFF ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-1521
Mailing Address - Country:US
Mailing Address - Phone:303-455-2409
Mailing Address - Fax:
Practice Address - Street 1:3035 W 25TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-4635
Practice Address - Country:US
Practice Address - Phone:303-455-2409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9923611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty