Healthcare Provider Details

I. General information

NPI: 1619031176
Provider Name (Legal Business Name): VICTORIA SUZANNE SHEPHERD L.P.C, L.A.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E MONROE AVE
MCALESTER OK
74501-4815
US

IV. Provider business mailing address

PO BOX 579
MCALESTER OK
74502-0579
US

V. Phone/Fax

Practice location:
  • Phone: 918-426-7844
  • Fax: 918-426-5526
Mailing address:
  • Phone: 918-426-7844
  • Fax: 918-426-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number454
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2342
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: