Provider Demographics
NPI:1982148094
Name:SHEPHERD, MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179-00 LINDEN BLVD. BLDG 91 RM E241
Mailing Address - Street 2:ST. ALBANS E.C.C./DEPT. OF VA
Mailing Address - City:ST. ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11425
Mailing Address - Country:US
Mailing Address - Phone:347-534-6898
Mailing Address - Fax:
Practice Address - Street 1:179-00 LINDEN BLVD. BLDG 91 RM E241
Practice Address - Street 2:ST. ALBANS E.C.C./DEPT. OF VA
Practice Address - City:ST. ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11425
Practice Address - Country:US
Practice Address - Phone:347-534-6898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084926-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical