Provider Demographics
NPI:1225222623
Name:SHIELDS, GLENN A (LISW)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STRANAHAN SQ
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1447
Mailing Address - Country:US
Mailing Address - Phone:419-244-5511
Mailing Address - Fax:419-321-6459
Practice Address - Street 1:1616 E WOOSTER ST
Practice Address - Street 2:SUITE 24
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-3478
Practice Address - Country:US
Practice Address - Phone:419-352-4624
Practice Address - Fax:419-354-1774
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 00050201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSHSW27531Medicare PIN