Basic Information
| Provider Information | |||||||||
| NPI: | 1699158816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | YVONNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL | ||||||||
| OtherFirstName: | YVONNE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3402 PRESTON ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132447177 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11000 W MCNICHOLS RD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482212357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133404442 | ||||||||
| FaxNumber: | 3133404443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1348886 | 05 | MI | MEDICAID | 291998 | 05 | MI | MEDICAID | 358813 | 05 | MI | MEDICAID | 24957 | 05 | MI | MEDICAID |