Basic Information
| Provider Information | |||||||||
| NPI: | 1962014340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPARD | ||||||||
| FirstName: | BRENNA | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOPPES | ||||||||
| OtherFirstName: | BRENNA | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1832 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667621832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202319873 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | PARSONS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673574951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202319873 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2020 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 11850 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 12143 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.