Provider Demographics
NPI:1013573294
Name:SHEPHARD, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:SHEPHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 NABBLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2837
Mailing Address - Country:US
Mailing Address - Phone:321-243-3831
Mailing Address - Fax:
Practice Address - Street 1:85 BULLDOG BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3319
Practice Address - Country:US
Practice Address - Phone:561-790-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW133221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRJ468OtherHFMG MA