Healthcare Provider Details

I. General information

NPI: 1548698921
Provider Name (Legal Business Name): KEARA SHEPPARD LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6334 LITTLEROCK RD SW BLDG 6
TUMWATER WA
98512-7332
US

IV. Provider business mailing address

6334 LITTLEROCK RD SW BLDG 6
TUMWATER WA
98512-7332
US

V. Phone/Fax

Practice location:
  • Phone: 360-704-7590
  • Fax: 360-704-7591
Mailing address:
  • Phone: 360-704-7590
  • Fax: 360-704-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11997
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60777893
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: