Healthcare Provider Details

I. General information

NPI: 1588088124
Provider Name (Legal Business Name): ROSANA SHIELDS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98120 QUEENS BLVD
REGO PARK NY
11374-4357
US

IV. Provider business mailing address

98120 QUEENS BLVD
REGO PARK NY
11374-4357
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0246
  • Fax: 718-830-9088
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005566
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: