Provider Demographics
NPI:1134177355
Name:SHEPHERD, MARYKAY (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:MARYKAY
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 COUNTY ROAD 4186
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-5005
Mailing Address - Country:US
Mailing Address - Phone:903-967-2629
Mailing Address - Fax:903-967-2629
Practice Address - Street 1:371 COUNTY ROAD 4186
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-5005
Practice Address - Country:US
Practice Address - Phone:903-967-2629
Practice Address - Fax:903-967-2629
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16204101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional