Healthcare Provider Details

I. General information

NPI: 1497891121
Provider Name (Legal Business Name): VIVIAN TARVIN SHIELDS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FOREST VALLEY DR
JACKSON MS
39212-3800
US

IV. Provider business mailing address

263 FOREST VALLEY DRIVE
JACKSON MS
39212
US

V. Phone/Fax

Practice location:
  • Phone: 601-371-8937
  • Fax:
Mailing address:
  • Phone: 601-371-8937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0269
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: