Provider Demographics
NPI:1598268781
Name:SHIELDS, MARK RANDALL (MED, LPC, CRAADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RANDALL
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:MED, LPC, CRAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 CARDINAL ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3750
Mailing Address - Country:US
Mailing Address - Phone:573-529-9496
Mailing Address - Fax:
Practice Address - Street 1:1303 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1943
Practice Address - Country:US
Practice Address - Phone:573-529-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO511101YA0400X
MOCS001167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)