Provider Demographics
NPI:1689848228
Name:SHEPPARD, SUSAN ANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNE
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5904
Mailing Address - Country:US
Mailing Address - Phone:616-451-3001
Mailing Address - Fax:616-451-8779
Practice Address - Street 1:1115 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-451-3001
Practice Address - Fax:616-451-8779
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010844101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical