Provider Demographics
NPI:1326568627
Name:SHIELDS, GINA
Entity type:Individual
Prefix:MS
First Name:GINA
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 1:1076 E SOUTH WEBER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405-9210
Mailing Address - Country:US
Mailing Address - Phone:801-889-5692
Mailing Address - Fax:
Practice Address - Street 1:415 MEDICAL DRIVE
Practice Address - Street 2:SUITE D101
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12735328-6009101YM0800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health