Provider Demographics
NPI:1255831558
Name:SHEPHERD, KRISTEN LEIGHANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LEIGHANNE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5021
Mailing Address - Country:US
Mailing Address - Phone:248-444-1735
Mailing Address - Fax:
Practice Address - Street 1:10 W 30TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5021
Practice Address - Country:US
Practice Address - Phone:248-444-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010941511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical