Provider Demographics
NPI:1598046757
Name:SHIELDS, BETH ANN (MT)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 TAINTER ST
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1568
Mailing Address - Country:US
Mailing Address - Phone:715-597-2316
Mailing Address - Fax:
Practice Address - Street 1:1309 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2959
Practice Address - Country:US
Practice Address - Phone:715-233-6230
Practice Address - Fax:715-233-6231
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11124-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist