Provider Demographics
NPI:1952791832
Name:SHEPHERD, CHRIS G (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:G
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3563 ANTENNA FARM RD SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-7601
Mailing Address - Country:US
Mailing Address - Phone:440-787-3087
Mailing Address - Fax:
Practice Address - Street 1:630 N FODALE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3538
Practice Address - Country:US
Practice Address - Phone:910-457-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2655225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant