Provider Demographics
NPI:1558903005
Name:SHEPHERD, MASON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MASON
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 EDPAS RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3811
Mailing Address - Country:US
Mailing Address - Phone:973-303-9237
Mailing Address - Fax:
Practice Address - Street 1:636 EDPAS RD
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-3811
Practice Address - Country:US
Practice Address - Phone:973-303-9237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
NJ35SI00652900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool