Provider Demographics
NPI:1356000871
Name:SHEPHERD, ANGELA (LBSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-0189
Mailing Address - Country:US
Mailing Address - Phone:517-592-1702
Mailing Address - Fax:517-592-1975
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-8979
Practice Address - Country:US
Practice Address - Phone:517-592-1702
Practice Address - Fax:517-592-1975
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086728104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871508309Medicaid