Basic Information
| Provider Information | |||||||||
| NPI: | 1043273212 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SHEPHERD | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657694545 | ||||||||
| FaxNumber: | 8657694501 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 FORT SANDERS WEST BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584491 | ||||||||
| FaxNumber: | 8655584493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7047 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3645143 | 05 | TN | MEDICAID | 4103368 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |