Healthcare Provider Details

I. General information

NPI: 1760131361
Provider Name (Legal Business Name): MELISSA SHEPARD, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 DUKE ST STE 107
PRINCE FREDERICK MD
20678-6128
US

IV. Provider business mailing address

4117 PARK RD # 12235
CHARLOTTE NC
28209-2214
US

V. Phone/Fax

Practice location:
  • Phone: 704-274-2219
  • Fax: 704-582-7160
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTHA MONTJOY KEARSE
Title or Position: VICE PRESIDENT
Credential:
Phone: 704-274-2219