Provider Demographics
NPI:1982321964
Name:SHINE PEDIATRIC PSYCHOLOGY SERVICES PLLC
Entity Type:Organization
Organization Name:SHINE PEDIATRIC PSYCHOLOGY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHER-SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-282-5250
Mailing Address - Street 1:2449 N PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-2669
Mailing Address - Country:US
Mailing Address - Phone:601-282-5250
Mailing Address - Fax:601-286-5305
Practice Address - Street 1:2449 N PARK DR STE C
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-2669
Practice Address - Country:US
Practice Address - Phone:601-282-5250
Practice Address - Fax:601-286-5305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health