MEDICARE: BRYAN SHEPARD LCSW

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	1041C0700X	Clinical Social Worker	34008606A	IN

General Provider Information

NPI Number	:	1366828865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN SHEPARD LCSW

Provider Business Mailing Address
First Line	:	520 S WALNUT ST # 3126
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-4618
Country	:	US
Telephone Number	:	812-502-4100
Fax Number	:	812-502-4200

Provider Business Practice Location Address
First Line	:	520 S WALNUT ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-4618
Country	:	US
Telephone Number	:	812-502-4100
Fax Number	:	812-502-4200

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

Provider Enumeration Date	:	08/06/2015
Last Update Date	:	11/23/2021

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