Healthcare Provider Details

I. General information

NPI: 1619881646
Provider Name (Legal Business Name): WANDA IVETTE SHEPPARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 CHETWOOD CIR APT 203
TIMONIUM MD
21093-2429
US

IV. Provider business mailing address

2310 CHETWOOD CIR APT 203
TIMONIUM MD
21093-2429
US

V. Phone/Fax

Practice location:
  • Phone: 570-369-9609
  • Fax:
Mailing address:
  • Phone: 570-369-9609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADT4301
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: