Provider Demographics
NPI:1245391887
Name:SHEPHERD, WALTER PHILIP (PHD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:PHILIP
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 MANGO PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3325
Mailing Address - Country:US
Mailing Address - Phone:904-346-0092
Mailing Address - Fax:904-346-0586
Practice Address - Street 1:2149 MANGO PL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3325
Practice Address - Country:US
Practice Address - Phone:904-346-0092
Practice Address - Fax:904-346-0586
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75701Medicare ID - Type Unspecified
R04213Medicare UPIN