Provider Demographics
NPI:1265507867
Name:SHIELDS, JUDITH I (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:I
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JUDIE
Other - Middle Name:I
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 21753
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:216-262-6206
Mailing Address - Fax:
Practice Address - Street 1:2469 FAIRMOUNT BLVD
Practice Address - Street 2:STE. 320
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-262-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5276103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP21974Medicare ID - Type Unspecified