Provider Demographics
NPI:1689792822
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 1:13400 S ROUTE 59
Mailing Address - Street 2:SUITE# 116-326
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-5696
Mailing Address - Country:US
Mailing Address - Phone:815-267-7334
Mailing Address - Fax:630-429-9411
Practice Address - Street 1:13400 S ROUTE 59
Practice Address - Street 2:SUITE# 116-326
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5696
Practice Address - Country:US
Practice Address - Phone:815-267-7334
Practice Address - Fax:630-429-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005672101YP2500X
IL070.0169382251P0200X
IL056.004242225XP0200X
IL146.004828235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932502OtherBCBS OF IL