MEDICARE: COURTNEY NICOLE SHIELDS LCADC, LCSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	246586	KY
2	1041C0700X	Clinical Social Worker	255310	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700390218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY NICOLE SHIELDS LCADC, LCSW

Provider Business Mailing Address
First Line	:	805 ALEXA DR STE D
Second Line	:
City	:	MT STERLING
State	:	KY
Zip	:	40353-1000
Country	:	US
Telephone Number	:	859-432-8002
Fax Number	:	859-432-8483

Provider Business Practice Location Address
First Line	:	805 ALEXA DR STE D
Second Line	:
City	:	MT STERLING
State	:	KY
Zip	:	40353-1000
Country	:	US
Telephone Number	:	859-432-8002
Fax Number	:	859-432-8483

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

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	12/10/2020

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