Provider Demographics
NPI:1760027320
Name:SHEPARD, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 GA HWY 32 BYPASS
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510
Mailing Address - Country:US
Mailing Address - Phone:912-632-6321
Mailing Address - Fax:912-632-6322
Practice Address - Street 1:139 GA HWY 32 BYPASS
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510
Practice Address - Country:US
Practice Address - Phone:912-632-6321
Practice Address - Fax:912-632-6322
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005905225X00000X
GAPT011608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty