Provider Demographics
NPI:1750141230
Name:SHINING LIGHT BEHAVIORAL HEALTH - WHITTAKER
Entity type:Organization
Organization Name:SHINING LIGHT BEHAVIORAL HEALTH - WHITTAKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:757-434-1828
Mailing Address - Street 1:500 E MAIN ST STE 1600-65
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2205
Mailing Address - Country:US
Mailing Address - Phone:757-434-1828
Mailing Address - Fax:
Practice Address - Street 1:9524 WHITTAKER DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4527
Practice Address - Country:US
Practice Address - Phone:757-453-5960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHINING LIGHT BEHAVIORAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
No252Y00000XAgenciesEarly Intervention Provider Agency
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient