Provider Demographics
NPI:1942657069
Name:SHEPARD-RHODES, CLARISA
Entity Type:Individual
Prefix:
First Name:CLARISA
Middle Name:
Last Name:SHEPARD-RHODES
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 1:251 NE GARDEN VALLEY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1498
Mailing Address - Country:US
Mailing Address - Phone:541-440-0933
Mailing Address - Fax:541-440-3707
Practice Address - Street 1:251 NE GARDEN VALLEY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1498
Practice Address - Country:US
Practice Address - Phone:541-440-0933
Practice Address - Fax:541-440-3707
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-2108171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR149192Medicaid