Provider Demographics
NPI:1659535821
Name:SHEPPARD, MARK GREGORY I (LCDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:GREGORY
Last Name:SHEPPARD
Suffix:I
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 CUSTER RD
Mailing Address - Street 2:265
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-4419
Mailing Address - Country:US
Mailing Address - Phone:972-985-7565
Mailing Address - Fax:888-664-0571
Practice Address - Street 1:3131 CUSTER RD
Practice Address - Street 2:265
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-4419
Practice Address - Country:US
Practice Address - Phone:972-985-7565
Practice Address - Fax:888-664-0571
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)