Provider Demographics
NPI:1386162402
Name:SHIELDS, KYLENE (LCSW)
Entity type:Individual
Prefix:
First Name:KYLENE
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 N COULSON DR
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-2558
Mailing Address - Country:US
Mailing Address - Phone:801-830-3021
Mailing Address - Fax:
Practice Address - Street 1:600 S GENEVA RD
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5803
Practice Address - Country:US
Practice Address - Phone:860-987-8020
Practice Address - Fax:860-987-8020
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9016760-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical