Provider Demographics
NPI:1184099947
Name:SHEPARD, GERALD (CACI)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 KIKER ST
Mailing Address - Street 2:
Mailing Address - City:TALLAPOOSA
Mailing Address - State:GA
Mailing Address - Zip Code:30176-1340
Mailing Address - Country:US
Mailing Address - Phone:404-809-7139
Mailing Address - Fax:
Practice Address - Street 1:180 WATER OAK DR
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2095
Practice Address - Country:US
Practice Address - Phone:770-748-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)