Provider Demographics
NPI:1588796585
Name:SHEPARD, ELIZABETH (PHD, CPCI)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PHD, CPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 REED AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1827
Mailing Address - Country:US
Mailing Address - Phone:801-243-8600
Mailing Address - Fax:
Practice Address - Street 1:231 E 400 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2803
Practice Address - Country:US
Practice Address - Phone:801-595-0666
Practice Address - Fax:801-595-0669
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT259707-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health