Provider Demographics
NPI:1790856532
Name:SHEPARDSON, MARY BETH (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:SHEPARDSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VALLEY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13365-1126
Mailing Address - Country:US
Mailing Address - Phone:315-823-3719
Mailing Address - Fax:
Practice Address - Street 1:7 TIMMERMAN AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-1017
Practice Address - Country:US
Practice Address - Phone:518-568-5037
Practice Address - Fax:518-568-5477
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006224-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131093Medicaid