Provider Demographics
NPI:1780916858
Name:SHEPARD, SUE (MFT)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MALLORN DR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5255
Mailing Address - Country:US
Mailing Address - Phone:714-751-0888
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST
Practice Address - Street 2:G-201
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5981
Practice Address - Country:US
Practice Address - Phone:714-751-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37470106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist