Provider Demographics
NPI:1164418570
Name:SHEPHERD, CAROLE
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:
Other - Last Name:SHEPHERD-RADENSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, LMT
Mailing Address - Street 1:252 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-8558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 E 61ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-8558
Practice Address - Country:US
Practice Address - Phone:212-888-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0692481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN22X81Medicare ID - Type Unspecified