Provider Demographics
NPI:1083662480
Name:SHIELDS, ADRIENNE (LPC)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 BROADMOOR DR
Mailing Address - Street 2:SUITE A-103
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2847
Mailing Address - Country:US
Mailing Address - Phone:979-315-4705
Mailing Address - Fax:
Practice Address - Street 1:2402 BROADMOOR DR
Practice Address - Street 2:SUITE A-103
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2847
Practice Address - Country:US
Practice Address - Phone:979-315-4705
Practice Address - Fax:979-774-0606
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1525537-02Medicaid