Healthcare Provider Details

I. General information

NPI: 1578826277
Provider Name (Legal Business Name): KIMBERLY M. SHEPHERD MSW, P-LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SUNNYBROOK RD
RALEIGH NC
27610-1827
US

IV. Provider business mailing address

107 SUNNYBROOK RD
RALEIGH NC
27610-1827
US

V. Phone/Fax

Practice location:
  • Phone: 919-250-1260
  • Fax:
Mailing address:
  • Phone: 919-250-1260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP007429
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: