Provider Demographics
NPI:1366828865
Name:SHEPARD, BRYAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S WALNUT ST # 3126
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4618
Mailing Address - Country:US
Mailing Address - Phone:812-502-4100
Mailing Address - Fax:812-502-4200
Practice Address - Street 1:520 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4618
Practice Address - Country:US
Practice Address - Phone:812-502-4100
Practice Address - Fax:812-502-4200
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008606A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical