Healthcare Provider Details

I. General information

NPI: 1285198457
Provider Name (Legal Business Name): ANGELA ELLEN JANE SHEPARD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE
ALBUQUERQUE NM
87110-3532
US

IV. Provider business mailing address

740 VALENCIA DR SE
ALBUQUERQUE NM
87108-3745
US

V. Phone/Fax

Practice location:
  • Phone: 505-804-1360
  • Fax:
Mailing address:
  • Phone: 505-804-1360
  • Fax: 505-254-4594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11660
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: