Provider Demographics
NPI:1417529645
Name:SHIELDS, STACEY RENEE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:RENEE
Other - Last Name:YERK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 TERRY CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19518-1534
Mailing Address - Country:US
Mailing Address - Phone:484-300-0708
Mailing Address - Fax:
Practice Address - Street 1:13 TERRY CT
Practice Address - Street 2:
Practice Address - City:DOUGLASSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19518-1534
Practice Address - Country:US
Practice Address - Phone:484-300-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005362103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst