Healthcare Provider Details

I. General information

NPI: 1538365739
Provider Name (Legal Business Name): ELIZABETH LAUREN SHEPARD ITDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 1ST ST
INDIAN ROCKS BEACH FL
33785-3134
US

IV. Provider business mailing address

2708 1ST ST
INDIAN ROCKS BEACH FL
33785-3134
US

V. Phone/Fax

Practice location:
  • Phone: 813-464-1810
  • Fax:
Mailing address:
  • Phone: 813-464-1810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: