Provider Demographics
NPI:1477618098
Name:SHEPARD, DEMETRIOUS THOMAS (LPC)
Entity Type:Individual
Prefix:MRS
First Name:DEMETRIOUS
Middle Name:THOMAS
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 OLD CHADWICK LANE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:910-347-1694
Mailing Address - Fax:910-347-3694
Practice Address - Street 1:824 GUM BRANCH RD STE E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6270
Practice Address - Country:US
Practice Address - Phone:910-327-1694
Practice Address - Fax:910-347-3694
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1378XOtherBCBS
NC6102002Medicaid