Healthcare Provider Details

I. General information

NPI: 1366386732
Provider Name (Legal Business Name): SYDNEY SHEPARD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GALLBERRY LN
WAXHAW NC
28173-0161
US

IV. Provider business mailing address

7741 LIBERTY ROW DR APT 404
CHARLOTTE NC
28210-4993
US

V. Phone/Fax

Practice location:
  • Phone: 704-649-4509
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number18402
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: