Healthcare Provider Details

I. General information

NPI: 1679511927
Provider Name (Legal Business Name): JUSTIN RYAN SHEPHERD MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 OFFICE PARK DR STE 150
MOUNTAIN BRK AL
35223-2400
US

IV. Provider business mailing address

800 CRESCENT CENTRE DR STE 600
FRANKLIN TN
37067-7286
US

V. Phone/Fax

Practice location:
  • Phone: 205-278-2250
  • Fax: 205-543-2034
Mailing address:
  • Phone: 615-373-1350
  • Fax: 615-221-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6646
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH7280
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: