Provider Demographics
NPI:1952822587
Name:SHINE WELLNESS CLINIC, PLLC
Entity Type:Organization
Organization Name:SHINE WELLNESS CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BABA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-531-5333
Mailing Address - Street 1:1 N STARKWEATHER ALY FL 3
Mailing Address - Street 2:
Mailing Address - City:ROMEO
Mailing Address - State:MI
Mailing Address - Zip Code:48065-4690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 N STARKWEATHER ALY FL 3
Practice Address - Street 2:
Practice Address - City:ROMEO
Practice Address - State:MI
Practice Address - Zip Code:48065-4690
Practice Address - Country:US
Practice Address - Phone:586-281-6815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091649104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty