Basic Information
| Provider Information | |||||||||
| NPI: | 1568087609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPHARD | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8898 CLAIREMONT MESA BLVD STE H | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587151211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8898 CLAIREMONT MESA BLVD STE H | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587151211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 10787 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.