Provider Demographics
NPI:1023274388
Name:SHEPARD, BLAIR W
Entity type:Individual
Prefix:MS
First Name:BLAIR
Middle Name:W
Last Name:SHEPARD
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 1:303 LUNA ST SE
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9277
Mailing Address - Country:US
Mailing Address - Phone:505-565-1619
Mailing Address - Fax:
Practice Address - Street 1:5312 JAGUAR DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-1827
Practice Address - Country:US
Practice Address - Phone:505-820-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0121891101YM0800X
NM0119171101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health