Healthcare Provider Details

I. General information

NPI: 1285318527
Provider Name (Legal Business Name): MADISON SHIELDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 N DUTTON AVE STE 230
SANTA ROSA CA
95401-4658
US

IV. Provider business mailing address

1160 N DUTTON AVE STE 230
SANTA ROSA CA
95401-4658
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-3243
  • Fax:
Mailing address:
  • Phone: 707-303-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22186
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: