Provider Demographics
NPI:1043591340
Name:SHEPARD, TARA KAY
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KAY
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:KAY
Other - Last Name:LIZBINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18119 RED OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2776
Mailing Address - Country:US
Mailing Address - Phone:734-748-4826
Mailing Address - Fax:800-248-1568
Practice Address - Street 1:13001 23 MILE RD STE 103
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-2767
Practice Address - Country:US
Practice Address - Phone:586-496-4398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361005957103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382230613OtherFIN #