Provider Demographics
NPI:1053923771
Name:SOUL SHINE MENTAL HEALTH THERAPY, LLC
Entity type:Organization
Organization Name:SOUL SHINE MENTAL HEALTH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:SZABO
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:440-823-1924
Mailing Address - Street 1:PO BOX 670702
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-0702
Mailing Address - Country:US
Mailing Address - Phone:440-823-1924
Mailing Address - Fax:
Practice Address - Street 1:11937 DUNHAM RD
Practice Address - Street 2:
Practice Address - City:SAGAMORE HILLS
Practice Address - State:OH
Practice Address - Zip Code:44067-1015
Practice Address - Country:US
Practice Address - Phone:440-823-1924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0261928Medicaid