Provider Demographics
NPI:1063039139
Name:KASEY SHEPHERD LSCSW LLC
Entity Type:Organization
Organization Name:KASEY SHEPHERD LSCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-516-2339
Mailing Address - Street 1:8911 E ORME ST STE D
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-2424
Mailing Address - Country:US
Mailing Address - Phone:316-425-7774
Mailing Address - Fax:316-425-7779
Practice Address - Street 1:8911 E ORME ST STE D
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-2424
Practice Address - Country:US
Practice Address - Phone:316-425-7774
Practice Address - Fax:316-425-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201259410AMedicaid