Provider Demographics
NPI:1083977169
Name:SHEPHERD, DANIEL ROY (DMIN, LLPC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROY
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DMIN, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 AXTELL ROAD
Mailing Address - Street 2:APT 6
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4419
Mailing Address - Country:US
Mailing Address - Phone:248-687-9251
Mailing Address - Fax:
Practice Address - Street 1:1202 WALTON BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6917
Practice Address - Country:US
Practice Address - Phone:248-650-8383
Practice Address - Fax:248-650-4343
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013084101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
12400604OtherCAQH