Provider Demographics
NPI:1841885373
Name:SHEPHERD, MELISSA DIANE (MA)
Entity type:Individual
Prefix:MR
First Name:MELISSA
Middle Name:DIANE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 MCCLURE RD
Mailing Address - Street 2:
Mailing Address - City:GILLSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30543-4626
Mailing Address - Country:US
Mailing Address - Phone:770-979-1074
Mailing Address - Fax:
Practice Address - Street 1:334 PROSPECT CHURCH RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-2217
Practice Address - Country:US
Practice Address - Phone:770-979-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006316101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health