Provider Demographics
NPI:1639962442
Name:A SHINING LIGHT PEDIATRIC THERAPY SERVICES, LLC
Entity type:Organization
Organization Name:A SHINING LIGHT PEDIATRIC THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KAITLIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:256-736-3056
Mailing Address - Street 1:7470 COUNTY ROAD 437
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35057-3325
Mailing Address - Country:US
Mailing Address - Phone:256-736-3056
Mailing Address - Fax:
Practice Address - Street 1:7470 COUNTY ROAD 437
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35057-3325
Practice Address - Country:US
Practice Address - Phone:256-736-3056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-24
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4624OtherALABAMA BOARD OF OCCUPATIONAL THERAPY