Provider Demographics
NPI:1780789420
Name:SHEPHERD, TEREASA DIANNE (PT, MSHA)
Entity type:Individual
Prefix:
First Name:TEREASA
Middle Name:DIANNE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:PT, MSHA
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:D
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, MSHA
Mailing Address - Street 1:595 N COURTENAY PKWY
Mailing Address - Street 2:#203
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4851
Mailing Address - Country:US
Mailing Address - Phone:321-453-8484
Mailing Address - Fax:321-453-8448
Practice Address - Street 1:595 N COURTENAY PKWY
Practice Address - Street 2:#203
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4851
Practice Address - Country:US
Practice Address - Phone:321-453-8484
Practice Address - Fax:321-453-8448
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY904DOtherBCBS
FL043709119002OtherTRICARE
FLY904DOtherBCBS