Provider Demographics
NPI:1255169959
Name:SHIELDS, TRACHELE
Entity type:Individual
Prefix:
First Name:TRACHELE
Middle Name:
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 1:3832 EVAN SAMUEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-0404
Mailing Address - Country:US
Mailing Address - Phone:904-710-5962
Mailing Address - Fax:
Practice Address - Street 1:8382 BAYMEADOWS RD STE 9
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7436
Practice Address - Country:US
Practice Address - Phone:904-755-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst