Provider Demographics
NPI:1205373016
Name:SHEPPARD, LUISA
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 E HIGHWAY 101 STE 3
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-9069
Mailing Address - Country:US
Mailing Address - Phone:362-452-4062
Mailing Address - Fax:360-452-4189
Practice Address - Street 1:3430 E HIGHWAY 101 STE 3
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-9069
Practice Address - Country:US
Practice Address - Phone:362-452-4062
Practice Address - Fax:360-452-4189
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60711557101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)