Provider Demographics
NPI:1083081103
Name:SHEPARD, ELISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 LA MIRADA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-2213
Mailing Address - Country:US
Mailing Address - Phone:562-903-4800
Mailing Address - Fax:
Practice Address - Street 1:12625 LA MIRADA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2213
Practice Address - Country:US
Practice Address - Phone:562-903-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26792103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical