Provider Demographics
NPI:1013445543
Name:SHEPHERD, MEGAN M (ATC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W PROSPECT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:635 W PROSPECT ST APT 1
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2494
Practice Address - Country:US
Practice Address - Phone:315-286-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-29
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0023902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer