Provider Demographics
NPI:1871022988
Name:MIND SHINE, LLC
Entity Type:Organization
Organization Name:MIND SHINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SABRIYA
Authorized Official - Middle Name:LAILA
Authorized Official - Last Name:SHARIF-HANIFA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCASA
Authorized Official - Phone:919-758-4559
Mailing Address - Street 1:8360 SIX FORKS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5087
Mailing Address - Country:US
Mailing Address - Phone:919-758-4559
Mailing Address - Fax:
Practice Address - Street 1:8360 SIX FORKS RD STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5087
Practice Address - Country:US
Practice Address - Phone:919-758-4559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty