Provider Demographics
NPI:1851735112
Name:SHIELDS, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHIELDS
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 1:465 NE VANDA TERRADO
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-6671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 SOUTH FEDERAL HY STE 200-B
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-6671
Practice Address - Country:US
Practice Address - Phone:772-349-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2106106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist