Provider Demographics
NPI:1053457374
Name:SHIELDS, VICTORIA A
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:A
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-3207
Mailing Address - Country:US
Mailing Address - Phone:631-264-0026
Mailing Address - Fax:
Practice Address - Street 1:NYSARC INC., SUFFOLK CHAPTER
Practice Address - Street 2:45 CROSSWAYS E.
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716
Practice Address - Country:US
Practice Address - Phone:631-218-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042373-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical