Provider Demographics
NPI:1740484740
Name:SHEPPARD, ALEXANDRA (LMT, NCTMB)
Entity type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 WASHBURN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2827
Mailing Address - Country:US
Mailing Address - Phone:978-314-0554
Mailing Address - Fax:
Practice Address - Street 1:85 E ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2870
Practice Address - Country:US
Practice Address - Phone:978-314-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT 1640225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist