Healthcare Provider Details

I. General information

NPI: 1114392578
Provider Name (Legal Business Name): PHOEBE SHEPPARD LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 05/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 SULPHUR SPRING RD
HALETHORPE MD
21227-2539
US

IV. Provider business mailing address

1634 SULPHUR SPRING RD
HALETHORPE MD
21227-2539
US

V. Phone/Fax

Practice location:
  • Phone: 410-242-0920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number21031
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: