Provider Demographics
NPI:1689222093
Name:SHEPARD, LORI DIANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:DIANE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4752 LLUVIA ENCANTADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-0857
Mailing Address - Country:US
Mailing Address - Phone:832-573-3932
Mailing Address - Fax:
Practice Address - Street 1:2504 CAMINO ENTRADA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4851
Practice Address - Country:US
Practice Address - Phone:505-471-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-102761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical