MEDICARE: ELIZABETH LAUREN SHEPARD ITDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1538365739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH LAUREN SHEPARD ITDS

Provider Business Mailing Address
First Line	:	2708 1ST ST
Second Line	:
City	:	INDIAN ROCKS BEACH
State	:	FL
Zip	:	33785-3134
Country	:	US
Telephone Number	:	813-464-1810
Fax Number	:

Provider Business Practice Location Address
First Line	:	2708 1ST ST
Second Line	:
City	:	INDIAN ROCKS BEACH
State	:	FL
Zip	:	33785-3134
Country	:	US
Telephone Number	:	813-464-1810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/09/2007

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