Basic Information
| Provider Information | |||||||||
| NPI: | 1821229576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPHERD | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | HUMAN SERVICES COORD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 STONEY LANDING ROAD | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618282 | ||||||||
| FaxNumber: | 8437617308 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 STONEY LANDING ROAD | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618282 | ||||||||
| FaxNumber: | 8437617308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 00082652 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 7367 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6005782 | 05 | NC | MEDICAID |