Provider Demographics
NPI:1447513692
Name:SHEPARD, MARTHA ANN
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:ANN
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARTHA
Other - Middle Name:ANN
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:13101 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2216
Mailing Address - Country:US
Mailing Address - Phone:734-785-7701
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802057499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health