Provider Demographics
NPI:1770550774
Name:SHEPARD, ROBERT C (LICSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:C
Last Name:SHEPARD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 W RIVERSIDE AVE
Mailing Address - Street 2:LL2
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-1132
Mailing Address - Country:US
Mailing Address - Phone:509-455-8819
Mailing Address - Fax:509-455-8903
Practice Address - Street 1:1124 W RIVERSIDE AVE
Practice Address - Street 2:LL2
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-1132
Practice Address - Country:US
Practice Address - Phone:509-455-8819
Practice Address - Fax:509-455-8903
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000062731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8888981Medicare PIN