Basic Information
Provider Information | |||||||||
NPI: | 1477881381 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEPARD | ||||||||
FirstName: | CHERYL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISW-S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 439 CLOVER LN | ||||||||
Address2: |   | ||||||||
City: | ARCHBOLD | ||||||||
State: | OH | ||||||||
PostalCode: | 435023218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193881896 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6605 W CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436171000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198417701 | ||||||||
FaxNumber: | 4198411691 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2009 | ||||||||
LastUpdateDate: | 11/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I1500411-SUPV | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | S.0800328 | OH | N |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.