Provider Demographics
NPI:1508110974
Name:SHEPARD, KIRK M (LPC)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:M
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NE BROADWAY
Mailing Address - Street 2:#333
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-498-8102
Mailing Address - Fax:
Practice Address - Street 1:2100 NE BROADWAY
Practice Address - Street 2:#333
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-498-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4136101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health