MEDICARE: DIANA SHEPHARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	XXXX	OK

General Provider Information

NPI Number	:	1104264837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA SHEPHARD

Provider Business Mailing Address
First Line	:	2914 EPPERLY DR
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-3322
Country	:	US
Telephone Number	:	405-604-9790
Fax Number	:

Provider Business Practice Location Address
First Line	:	2914 EPPERLY DR
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-3322
Country	:	US
Telephone Number	:	405-604-9790
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2013
Last Update Date	:	06/04/2013

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Directions to “ DIANA SHEPHARD ” Practice Location

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