Provider Demographics
NPI:1023454816
Name:SHEPHARD, ELIZABETH JEAN (LMT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:SHEPHARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JEAN
Other - Last Name:SHEPHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:1170 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5346
Mailing Address - Country:US
Mailing Address - Phone:405-714-7662
Mailing Address - Fax:
Practice Address - Street 1:1032 1/2 MAIN AVE
Practice Address - Street 2:SUITE 30
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5124
Practice Address - Country:US
Practice Address - Phone:405-714-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0014703225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist