Provider Demographics
NPI:1831227529
Name:FIELDS, SHANTISE N (MS, IMF-74108)
Entity type:Individual
Prefix:MRS
First Name:SHANTISE
Middle Name:N
Last Name:FIELDS
Suffix:
Gender:F
Credentials:MS, IMF-74108
Other - Prefix:MISS
Other - First Name:SHANTISE
Other - Middle Name:N
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, MS
Mailing Address - Street 1:1721 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3312
Mailing Address - Country:US
Mailing Address - Phone:323-221-4134
Mailing Address - Fax:323-221-3231
Practice Address - Street 1:1721 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-3312
Practice Address - Country:US
Practice Address - Phone:323-221-4134
Practice Address - Fax:323-221-3231
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 74108106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist