Provider Demographics
NPI:1073745071
Name:SHIELDS, COLLEEN ANN
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:ANN
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 1:3339 MENTONE AVE
Mailing Address - Street 2:#8
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-4621
Mailing Address - Country:US
Mailing Address - Phone:310-837-4369
Mailing Address - Fax:
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-639-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31383167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician