Provider Demographics
NPI:1922359181
Name:SHIELDS, KATIE MARY (BST)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARY
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:BST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 W LAKE MEAD BLVD UNIT 119
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-7030
Mailing Address - Country:US
Mailing Address - Phone:702-335-4458
Mailing Address - Fax:
Practice Address - Street 1:5130 S PECOS RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1248
Practice Address - Country:US
Practice Address - Phone:102-560-5973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV101YM0800XMedicaid