Provider Demographics
NPI:1073296695
Name:SHIELDS, MIKAELA LESLIE (DPT)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:LESLIE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:DPT
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 121
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-0121
Mailing Address - Country:US
Mailing Address - Phone:207-272-3446
Mailing Address - Fax:
Practice Address - Street 1:1040 WHITTIER HWY
Practice Address - Street 2:
Practice Address - City:MOULTONBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03254
Practice Address - Country:US
Practice Address - Phone:603-273-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist