Healthcare Provider Details

I. General information

NPI: 1366123713
Provider Name (Legal Business Name): SAMANTHA SHEPPARD LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S UNIVERSITY AVE
CARBONDALE IL
62901-2925
US

IV. Provider business mailing address

212 S UNIVERSITY AVE
CARBONDALE IL
62901-2925
US

V. Phone/Fax

Practice location:
  • Phone: 203-200-0788
  • Fax:
Mailing address:
  • Phone: 860-506-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW04233
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149028454
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13925
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: