Provider Demographics
NPI:1932843109
Name:SHINE-PEDIATRIC THERAPY CENTER
Entity type:Organization
Organization Name:SHINE-PEDIATRIC THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRYCE-TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MOT/L
Authorized Official - Phone:850-353-2415
Mailing Address - Street 1:4565 COMMERCIAL DR STE 105
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8856
Mailing Address - Country:US
Mailing Address - Phone:850-353-2415
Mailing Address - Fax:850-353-2528
Practice Address - Street 1:4565 COMMERCIAL DR STE 105
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8856
Practice Address - Country:US
Practice Address - Phone:850-353-2415
Practice Address - Fax:850-353-2528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty