Provider Demographics
NPI:1053046235
Name:SHEPHERD, WILLIAM VIRGIL LEE III
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:VIRGIL LEE
Last Name:SHEPHERD
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6231 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-4531
Mailing Address - Country:US
Mailing Address - Phone:727-667-5426
Mailing Address - Fax:
Practice Address - Street 1:550 62ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1533
Practice Address - Country:US
Practice Address - Phone:727-347-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11955225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist