Provider Demographics
NPI:1285844944
Name:SHEPPARD, PETER LOREN (MS)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:LOREN
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 TULLY RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-571-6053
Mailing Address - Fax:209-571-6059
Practice Address - Street 1:1729 TULLY RD
Practice Address - Street 2:SUITE 8
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4082
Practice Address - Country:US
Practice Address - Phone:209-571-6053
Practice Address - Fax:209-571-6059
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC26034106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist