Provider Demographics
NPI:1770638322
Name:SHINE, GENICE MERY (MS)
Entity Type:Individual
Prefix:MRS
First Name:GENICE
Middle Name:MERY
Last Name:SHINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 JOLIE LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7177
Mailing Address - Country:US
Mailing Address - Phone:512-260-0183
Mailing Address - Fax:512-260-0183
Practice Address - Street 1:1112 JOLIE LN
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7177
Practice Address - Country:US
Practice Address - Phone:512-260-0183
Practice Address - Fax:512-260-0183
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5863101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional