Provider Demographics
NPI:1568914067
Name:SHIELDS, NICOLE PEARL (MS CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:PEARL
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 CORTEEN PL
Mailing Address - Street 2:APT 20
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2093
Mailing Address - Country:US
Mailing Address - Phone:661-644-4523
Mailing Address - Fax:
Practice Address - Street 1:5301 LAUREL CANYON BLVD
Practice Address - Street 2:245
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2736
Practice Address - Country:US
Practice Address - Phone:818-435-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP22057235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist