Provider Demographics
NPI:1417544875
Name:SHIELDS, MICHEAL (PHD)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1657
Mailing Address - Country:US
Mailing Address - Phone:620-617-3620
Mailing Address - Fax:
Practice Address - Street 1:29 HEATHERWOOD DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1657
Practice Address - Country:US
Practice Address - Phone:620-617-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2098103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling