Provider Demographics
NPI:1851041305
Name:SHEPPARD, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SHEPPARD
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 1:1826 EGRET CREST LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6071
Mailing Address - Country:US
Mailing Address - Phone:941-787-4780
Mailing Address - Fax:
Practice Address - Street 1:1341 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7307
Practice Address - Country:US
Practice Address - Phone:843-936-3385
Practice Address - Fax:843-388-4868
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4730225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant