Provider Demographics
NPI:1942783436
Name:SHEPHERD, ADDIS LEE (THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:ADDIS
Middle Name:LEE
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9167
Mailing Address - Country:US
Mailing Address - Phone:270-325-1027
Mailing Address - Fax:270-765-2557
Practice Address - Street 1:THE COMMITMENT HOUSE
Practice Address - Street 2:115 PARKWAY DRIVE
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7827
Practice Address - Country:US
Practice Address - Phone:270-900-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY275079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY$$$$$$$$$Medicaid