Provider Demographics
NPI:1932411899
Name:SHEPHERD, MARY BETH (LPCA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6412 BANNINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1327
Mailing Address - Country:US
Mailing Address - Phone:704-336-9137
Mailing Address - Fax:704-541-1098
Practice Address - Street 1:6412 BANNINGTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1327
Practice Address - Country:US
Practice Address - Phone:704-336-9137
Practice Address - Fax:704-541-1098
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPCA8053101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional