Provider Demographics
NPI:1306000575
Name:SHEPHERD, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SHEPHERD
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 1:622 W COLLEGE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SAINT MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1822
Mailing Address - Country:US
Mailing Address - Phone:205-245-4363
Mailing Address - Fax:208-245-4349
Practice Address - Street 1:622 W COLLEGE AVE STE 2
Practice Address - Street 2:
Practice Address - City:SAINT MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1822
Practice Address - Country:US
Practice Address - Phone:205-245-4363
Practice Address - Fax:208-245-4349
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-288801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical