Provider Demographics
NPI:1407322712
Name:SHEPPARD, MINDI (SLP)
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:SLP
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 53738
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95153-0738
Mailing Address - Country:US
Mailing Address - Phone:408-608-8792
Mailing Address - Fax:
Practice Address - Street 1:2995 ROSSMORE WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-3527
Practice Address - Country:US
Practice Address - Phone:408-608-8792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17269235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17269OtherSPEECH AND LANGUAGE