MEDICARE: KENNETH L. SHIELDS LMHC

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	101YM0800X	Mental Health Counselor	39001242A	IN
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	87001425A	IN

General Provider Information

NPI Number	:	1548267743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH L. SHIELDS LMHC

Provider Business Mailing Address
First Line	:	11104 PARKVIEW CIRCLE DR
Second Line	:	STE 110
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1730
Country	:	US
Telephone Number	:	260-460-3203
Fax Number	:	260-460-3130

Provider Business Practice Location Address
First Line	:	11104 PARKVIEW CIRCLE DR
Second Line	:	STE 110
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1730
Country	:	US
Telephone Number	:	260-460-3203
Fax Number	:	260-460-3130

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

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	12/26/2012

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