Provider Demographics
NPI:1376741652
Name:SHEPHERD, REX ALAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:ALAN
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 N HIGHLAND AVE APT E4
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-1335
Mailing Address - Country:US
Mailing Address - Phone:727-447-8930
Mailing Address - Fax:
Practice Address - Street 1:910 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6600
Practice Address - Country:US
Practice Address - Phone:727-736-4804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20540225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant