Provider Demographics
NPI:1548267743
Name:SHIELDS, KENNETH L (LMHC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11104 PARKVIEW CIRCLE DR
Mailing Address - Street 2:STE 110
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1730
Mailing Address - Country:US
Mailing Address - Phone:260-460-3203
Mailing Address - Fax:260-460-3130
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR
Practice Address - Street 2:STE 110
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-460-3203
Practice Address - Fax:260-460-3130
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001242A101YM0800X
IN87001425A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)