Provider Demographics
NPI:1003225566
Name:SHEPHERD, LEONARD (MS)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 ROGERS AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3152
Mailing Address - Country:US
Mailing Address - Phone:479-276-8871
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE STE 180
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1077
Practice Address - Country:US
Practice Address - Phone:918-812-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-09
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL046364164W00000X
OK101Y00000X
MI4703084481164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200698990 AMedicaid