Provider Demographics
NPI:1043304231
Name:SHEPHERD, SUSAN J (LICSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6080
Mailing Address - Country:US
Mailing Address - Phone:802-254-5497
Mailing Address - Fax:
Practice Address - Street 1:22 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6080
Practice Address - Country:US
Practice Address - Phone:802-254-5497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900004481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
08028628OtherBCBS
VT1007083Medicaid
VT1007083Medicaid