Provider Demographics
NPI:1821229576
Name:SHEPHERD, SCOTT A (HUMAN SERVICES COORD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:HUMAN SERVICES COORD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 STONEY LANDING ROAD
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3967
Mailing Address - Country:US
Mailing Address - Phone:843-761-8282
Mailing Address - Fax:843-761-7308
Practice Address - Street 1:403 STONEY LANDING ROAD
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3967
Practice Address - Country:US
Practice Address - Phone:843-761-8282
Practice Address - Fax:843-761-7308
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00082652101YA0400X
NC7367101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005782Medicaid