MEDICARE: CHRISTINE M SHIELDS LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	049479-1	NY

General Provider Information

NPI Number	:	1427117498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE M SHIELDS LCSW-R

Provider Business Mailing Address
First Line	:	8 STANLEY CIR
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2606
Country	:	US
Telephone Number	:	518-786-0663
Fax Number	:	518-786-0917

Provider Business Practice Location Address
First Line	:	8 STANLEY CIR
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2606
Country	:	US
Telephone Number	:	518-786-0663
Fax Number	:	518-786-0917

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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