Healthcare Provider Details

I. General information

NPI: 1366266041
Provider Name (Legal Business Name): SAMANTHA KATHLEEN SHEPPARD MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA HAWKINS

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WALNUT ST
GREENVILLE OH
45331-1944
US

IV. Provider business mailing address

571 N CLAYTON RD
NEW LEBANON OH
45345-9641
US

V. Phone/Fax

Practice location:
  • Phone: 937-548-6842
  • Fax:
Mailing address:
  • Phone: 937-248-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2406611
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: