Provider Demographics
NPI:1881825180
Name:SHIELDES, MICHELE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:SHIELDES
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 EVERGLADES DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2005
Mailing Address - Country:US
Mailing Address - Phone:903-245-7720
Mailing Address - Fax:903-531-2451
Practice Address - Street 1:401 E FRONT ST STE 123
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8250
Practice Address - Country:US
Practice Address - Phone:903-531-2581
Practice Address - Fax:903-531-2451
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205565902Medicaid