Provider Demographics
NPI:1811998149
Name:SHEPHARD, LAWRENCE W (P,T,)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
Last Name:SHEPHARD
Suffix:
Gender:M
Credentials:P,T,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 MARCH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3363
Mailing Address - Country:US
Mailing Address - Phone:707-433-5219
Mailing Address - Fax:707-433-5248
Practice Address - Street 1:441 MARCH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3363
Practice Address - Country:US
Practice Address - Phone:707-433-5219
Practice Address - Fax:707-433-5248
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT60600Medicare ID - Type Unspecified