Basic Information
| Provider Information | |||||||||
| NPI: | 1831227529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIELDS | ||||||||
| FirstName: | SHANTISE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, IMF-74108 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | SHANTISE | ||||||||
| OtherMiddleName: | N. | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BA, MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1721 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900313312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232214134 | ||||||||
| FaxNumber: | 3232213231 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900313312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232214134 | ||||||||
| FaxNumber: | 3232213231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 74108 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.