Provider Demographics
NPI:1821652553
Name:SHIELD, SVJETLANA
Entity Type:Individual
Prefix:
First Name:SVJETLANA
Middle Name:
Last Name:SHIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 BRENTWOOD HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6141
Mailing Address - Country:US
Mailing Address - Phone:907-952-7236
Mailing Address - Fax:
Practice Address - Street 1:8800 49TH ST N STE 106
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-5332
Practice Address - Country:US
Practice Address - Phone:727-544-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRMHCI17676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health