Provider Demographics
NPI:1710059761
Name:SHEPHERD, CATHLEEN C
Entity Type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:C
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2896 KNOB HILL DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4201
Mailing Address - Country:US
Mailing Address - Phone:770-434-3999
Mailing Address - Fax:770-434-3999
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:SUITE 320
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:404-314-7518
Practice Address - Fax:770-434-3999
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000009225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA312669OtherWELLCARE
GA000624126COtherPEACH STATE HEALTH PLAN
GA000624126CMedicaid
GA52171845 001OtherBLUE CROSS BLUE SHIELD
GA52171845 003OtherBLUE CROSS BLUE SHIELD
GA10035954OtherAMERIGROUP
GA52171845 002OtherBLUE CROSS BLUE SHIELD