Provider Demographics
NPI:1902396591
Name:SHEPPARD, AUDREY DAWN (PLPC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:DAWN
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 LONE WOLF DR
Mailing Address - Street 2:
Mailing Address - City:GRAVOIS MILLS
Mailing Address - State:MO
Mailing Address - Zip Code:65037-6631
Mailing Address - Country:US
Mailing Address - Phone:573-525-7071
Mailing Address - Fax:573-525-7072
Practice Address - Street 1:89 MCCRORY DR
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020
Practice Address - Country:US
Practice Address - Phone:573-525-7071
Practice Address - Fax:573-525-7072
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018015969101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional