Basic Information
| Provider Information | |||||||||
| NPI: | 1700390218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCADC, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 805 ALEXA DR STE D | ||||||||
| Address2: | |||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594328002 | ||||||||
| FaxNumber: | 8594328483 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 ALEXA DR STE D | ||||||||
| Address2: | |||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594328002 | ||||||||
| FaxNumber: | 8594328483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 246586 | KY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 255310 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1790731081 | 05 | KY | MEDICAID |