Healthcare Provider Details

I. General information

NPI: 1770550774
Provider Name (Legal Business Name): ROBERT C. SHEPARD LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 W RIVERSIDE AVE LL2
SPOKANE WA
99201-1132
US

IV. Provider business mailing address

1124 W RIVERSIDE AVE LL2
SPOKANE WA
99201-1132
US

V. Phone/Fax

Practice location:
  • Phone: 509-455-8819
  • Fax: 509-455-8903
Mailing address:
  • Phone: 509-455-8819
  • Fax: 509-455-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00006273
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: