Provider Demographics
NPI:1700390218
Name:SHIELDS, COURTNEY NICOLE (LCADC, LCSW)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:LCADC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 ALEXA DR STE D
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1000
Mailing Address - Country:US
Mailing Address - Phone:859-432-8002
Mailing Address - Fax:859-432-8483
Practice Address - Street 1:805 ALEXA DR STE D
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1000
Practice Address - Country:US
Practice Address - Phone:859-432-8002
Practice Address - Fax:859-432-8483
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246586101YA0400X
KY2553101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid