=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972857274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL A SHEPHERD LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2012
-----------------------------------------------------
Last Update Date | 05/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 MOUNTAIN RD 2ND FLOOR
-----------------------------------------------------
City | SUFFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06078-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-370-5061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 MOUNTAIN RD 2ND FLOOR
-----------------------------------------------------
City | SUFFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06078-2084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-370-5061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 003452
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------