Provider Demographics
NPI:1710577689
Name:SHEPARD, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CONSTITUTION WAY STE C
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1199
Mailing Address - Country:US
Mailing Address - Phone:888-754-0398
Mailing Address - Fax:
Practice Address - Street 1:220 CENTRAL ST APT 8
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-4118
Practice Address - Country:US
Practice Address - Phone:573-300-6033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20-144163106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician