Provider Demographics
NPI:1023360443
Name:THE SHEPERD'S LODGE
Entity Type:Organization
Organization Name:THE SHEPERD'S LODGE
Other - Org Name:THE SHEPERD'S LODGE MINISTRIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ANN MARIE
Authorized Official - Middle Name:SHARON
Authorized Official - Last Name:RAMKISSOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-953-3128
Mailing Address - Street 1:2918 DUCK POINT DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8813
Mailing Address - Country:US
Mailing Address - Phone:704-953-3128
Mailing Address - Fax:
Practice Address - Street 1:2918 DUCK POINT DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8813
Practice Address - Country:US
Practice Address - Phone:704-953-3128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 251K00000X, 251S00000X, 305R00000X, 320600000X, 385H00000X, 385HR2050X
NCAPPLIED FOR251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp