Provider Demographics
NPI:1790895704
Name:SHIELDS, SANDRA JEAN (RN LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:RN LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087
Mailing Address - Country:US
Mailing Address - Phone:972-772-4006
Mailing Address - Fax:972-772-3547
Practice Address - Street 1:775 JUSTIN RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087
Practice Address - Country:US
Practice Address - Phone:972-772-4006
Practice Address - Fax:972-772-3547
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX184161041C0700X
TX431448163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S40YMedicaid
TX005409Medicare ID - Type Unspecified
064084901Medicare UPIN