Provider Demographics
NPI:1215480165
Name:SHIELDS, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
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 1:3112 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3310
Mailing Address - Country:US
Mailing Address - Phone:402-651-3809
Mailing Address - Fax:
Practice Address - Street 1:3112 W BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3310
Practice Address - Country:US
Practice Address - Phone:712-276-9000
Practice Address - Fax:712-276-4917
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2004101YM0800X
IA093854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health