Provider Demographics
NPI:1629046263
Name:SHEPPARD, TONY (PHD HSPP)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 N MARR RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-6660
Mailing Address - Country:US
Mailing Address - Phone:812-314-3400
Mailing Address - Fax:812-378-8367
Practice Address - Street 1:335 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4480
Practice Address - Country:US
Practice Address - Phone:812-258-0310
Practice Address - Fax:812-258-0409
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041852A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000320601OtherANTHEM PIN
IN143220QMedicare ID - Type Unspecified