=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124790290
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA S. SHEPARD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2021
-----------------------------------------------------
Last Update Date | 09/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16413 HOWARD DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48042-5783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-260-4116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16413 HOWARD DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48042-5783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-260-4116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROFESSIONAL COUNSELOR/OWNER
-----------------------------------------------------
Name | MS. LISA S SHEPARD
-----------------------------------------------------
Credential | MA LPC NCC
-----------------------------------------------------
Telephone | 586-260-4116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------