Basic Information
| Provider Information | |||||||||
| NPI: | 1306000815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | AT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BULLDOG DR | ||||||||
| Address2: | |||||||||
| City: | PLUMERVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721278803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013542269 | ||||||||
| FaxNumber: | 5013540167 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 HIGHWAY 9 | ||||||||
| Address2: | |||||||||
| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721109403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012085911 | ||||||||
| FaxNumber: | 5012085912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2008 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 206055721 | 05 | AR | MEDICAID |