Provider Demographics
NPI:1831490317
Name:SHEPHERD, CLINT
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:SHEPHERD
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:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:MARYSVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84750-0133
Mailing Address - Country:US
Mailing Address - Phone:435-201-9215
Mailing Address - Fax:435-527-8883
Practice Address - Street 1:8510 S TEN MILE RD
Practice Address - Street 2:
Practice Address - City:MARYSVALE
Practice Address - State:UT
Practice Address - Zip Code:84750
Practice Address - Country:US
Practice Address - Phone:435-201-9215
Practice Address - Fax:435-527-8883
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No101Y00000XBehavioral Health & Social Service ProvidersCounselor