Healthcare Provider Details

I. General information

NPI: 1902136005
Provider Name (Legal Business Name): HEATHER SHEPHERD M.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 ROANOKE AVE
RIVERHEAD NY
11901-2098
US

IV. Provider business mailing address

1380 ROANOKE AVE
RIVERHEAD NY
11901
US

V. Phone/Fax

Practice location:
  • Phone: 631-369-4418
  • Fax: 631-369-4421
Mailing address:
  • Phone: 631-369-4418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number085617
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: