Basic Information
| Provider Information | |||||||||
| NPI: | 1528252723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPARD | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213942660 | ||||||||
| FaxNumber: | 3213942669 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 S COURTENAY PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329524977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213942660 | ||||||||
| FaxNumber: | 3213942669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT7588 | FL | N | Other Service Providers | Specialist | 225100000X | PT7588 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | NT479 | 01 | FL | FL MEDICARE | OTHER |