Provider Demographics
NPI:1528667201
Name:SHINE FORTH LLC
Entity type:Organization
Organization Name:SHINE FORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JUDIANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-248-1789
Mailing Address - Street 1:6710 WILLSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2757
Mailing Address - Country:US
Mailing Address - Phone:719-248-1789
Mailing Address - Fax:
Practice Address - Street 1:6710 WILLSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-2757
Practice Address - Country:US
Practice Address - Phone:719-248-1789
Practice Address - Fax:307-514-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY153780600Medicaid