Provider Demographics
NPI:1558750604
Name:SHEPARD, CONNIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11607 RUTH POLK CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-4804
Mailing Address - Country:US
Mailing Address - Phone:704-904-9381
Mailing Address - Fax:
Practice Address - Street 1:2324 CONCORD LAKE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2814
Practice Address - Country:US
Practice Address - Phone:704-904-9381
Practice Address - Fax:704-461-4334
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0105611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty