Provider Demographics
NPI:1679389605
Name:SHIELDS, KELLI K
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:K
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 OAK BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3256
Mailing Address - Country:US
Mailing Address - Phone:864-569-5644
Mailing Address - Fax:
Practice Address - Street 1:223 OAK BRANCH DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-3256
Practice Address - Country:US
Practice Address - Phone:864-569-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst