Healthcare Provider Details

I. General information

NPI: 1639566219
Provider Name (Legal Business Name): MELISSA SHEPARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA SHEPARD

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BILLINGSLEY RD STE 108
CHARLOTTE NC
28211-3091
US

IV. Provider business mailing address

300 BILLINGSLEY RD STE 108
CHARLOTTE NC
28211-3091
US

V. Phone/Fax

Practice location:
  • Phone: 704-577-3186
  • Fax: 704-626-2701
Mailing address:
  • Phone: 704-577-3186
  • Fax: 704-626-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number6983
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2019-01063
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: