Provider Demographics
NPI:1568033538
Name:SHEPARD, DIANE A
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2534
Mailing Address - Country:US
Mailing Address - Phone:845-843-6400
Mailing Address - Fax:845-421-6804
Practice Address - Street 1:402 E MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2516
Practice Address - Country:US
Practice Address - Phone:845-843-6400
Practice Address - Fax:845-421-6804
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110991-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker