Provider Demographics
NPI:1558774901
Name:SHEPARD, PATRICIA (LICSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 A JACKSON AVE 2-2 EBH BLDG R 1880
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BAYNE JONES ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:1585 THIRD ST
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459
Practice Address - Country:US
Practice Address - Phone:337-531-3783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UNKNOWNOtherTRICARE