Healthcare Provider Details

I. General information

NPI: 1275097495
Provider Name (Legal Business Name): RAVEN MICHAELA SHIELDS BS MHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AMERICAN GREETING CARD RD
CORBIN KY
40701-4811
US

IV. Provider business mailing address

1585 KY 3437
GRAY KY
40734-6548
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-7010
  • Fax:
Mailing address:
  • Phone: 606-344-0113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: