Provider Demographics
NPI:1033116397
Name:SHEPARD, LAURIE L (PT, OCS)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:L
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 W WARNER RD
Mailing Address - Street 2:SUITE A 2
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2713
Mailing Address - Country:US
Mailing Address - Phone:480-821-2286
Mailing Address - Fax:480-821-2286
Practice Address - Street 1:6836 E BROWN RD
Practice Address - Street 2:STE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3756
Practice Address - Country:US
Practice Address - Phone:480-924-5514
Practice Address - Fax:480-924-5518
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-10-12
Deactivation Date:2005-07-01
Deactivation Code:
Reactivation Date:2005-07-12
Provider Licenses
StateLicense IDTaxonomies
AZ962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ054940Medicaid
AZZ29577Medicare PIN