Provider Demographics
NPI:1700382264
Name:SHEPEARD, TYRA (LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:TYRA
Middle Name:
Last Name:SHEPEARD
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:MS
Other - First Name:TYRA
Other - Middle Name:
Other - Last Name:HEARNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9221 GLENWATER DR APT 711
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8490
Mailing Address - Country:US
Mailing Address - Phone:302-377-4578
Mailing Address - Fax:
Practice Address - Street 1:609 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3810
Practice Address - Country:US
Practice Address - Phone:704-751-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0122181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical