Provider Demographics
NPI:1760939896
Name:SHEPHERD, TISHA
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:SHEPHERD
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 1:719 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331
Mailing Address - Country:US
Mailing Address - Phone:937-467-8055
Mailing Address - Fax:937-339-7816
Practice Address - Street 1:600 WALNUT ST.
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331
Practice Address - Country:US
Practice Address - Phone:937-335-0361
Practice Address - Fax:937-339-7816
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.160820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)