Provider Demographics
NPI:1366181083
Name:SHINE, ANGELA L (BSW, LMSW)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:SHINE
Suffix:
Gender:F
Credentials:BSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39703-0221
Mailing Address - Country:US
Mailing Address - Phone:615-243-0670
Mailing Address - Fax:
Practice Address - Street 1:110 FREESTONE RDG
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-4503
Practice Address - Country:US
Practice Address - Phone:615-243-0670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool