Provider Demographics
NPI:1356601389
Name:SHEPHERD, REGINA B (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:B
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:B
Other - Last Name:GAMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1680 GEORGETOWNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2008
Mailing Address - Country:US
Mailing Address - Phone:941-378-4662
Mailing Address - Fax:941-343-9402
Practice Address - Street 1:1680 GEORGETOWNE BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2008
Practice Address - Country:US
Practice Address - Phone:941-378-4662
Practice Address - Fax:941-343-9402
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist