Provider Demographics
NPI:1689687832
Name:SHEPHERDS LODGE INC.
Entity Type:Organization
Organization Name:SHEPHERDS LODGE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GUESS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:757-477-5957
Mailing Address - Street 1:3337 KILLIAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-6024
Mailing Address - Country:US
Mailing Address - Phone:757-393-3408
Mailing Address - Fax:757-397-0316
Practice Address - Street 1:3337 KILLIAN AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-6024
Practice Address - Country:US
Practice Address - Phone:757-393-3408
Practice Address - Fax:757-397-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA701320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities