Provider Demographics
NPI:1083344212
Name:SHEPARD, DIAMOND DAWN (LMT)
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:DAWN
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17004 NOVAK DR
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1156
Mailing Address - Country:US
Mailing Address - Phone:708-739-6990
Mailing Address - Fax:
Practice Address - Street 1:17004 NOVAK DR
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1156
Practice Address - Country:US
Practice Address - Phone:708-739-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-11
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227022203225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist