MEDICARE: MR. DURRELL SHEPPARD LCSW

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	1041C0700X	Clinical Social Worker	149.020290	IL

General Provider Information

NPI Number	:	1578059812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DURRELL SHEPPARD LCSW

Provider Business Mailing Address
First Line	:	9518 S 53RD AVE
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-2902
Country	:	US
Telephone Number	:	773-450-8043
Fax Number	:

Provider Business Practice Location Address
First Line	:	9518 S 53RD AVE
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-2902
Country	:	US
Telephone Number	:	773-450-8043
Fax Number	:

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

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	03/16/2022

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