Provider Demographics
NPI:1962682823
Name:SHEPHERD, DIANE LOIS (CDP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LOIS
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 W JOHN DAY AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2529
Mailing Address - Country:US
Mailing Address - Phone:509-735-1652
Mailing Address - Fax:
Practice Address - Street 1:3918 W COURT ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2775
Practice Address - Country:US
Practice Address - Phone:509-544-5761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)