Provider Demographics
NPI:1619289196
Name:SHEPHERD, MARK HARRISON (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HARRISON
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5130 WILSON BLVD # B1
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-1169
Mailing Address - Country:US
Mailing Address - Phone:703-527-9557
Mailing Address - Fax:703-526-0438
Practice Address - Street 1:5130 WILSON BLVD # B1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-1169
Practice Address - Country:US
Practice Address - Phone:703-527-9557
Practice Address - Fax:703-526-0438
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA23052065322251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic