1710905591 NPI number — MRS. JULIE MICHELLE SHEPPARD LCSW

Table of content: MRS. JULIE MICHELLE SHEPPARD LCSW (NPI 1710905591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710905591 NPI number — MRS. JULIE MICHELLE SHEPPARD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPPARD
Provider First Name:
JULIE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDERSON
Provider Other First Name:
JULIE
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710905591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2720 PARK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLESON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76028-6324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-810-0030
Provider Business Mailing Address Fax Number:
817-293-0382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 PARK PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-6324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-675-7087
Provider Business Practice Location Address Fax Number:
817-877-3562
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  22292 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 063894201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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