1942783436 NPI number — MR. ADDIS LEE SHEPHERD THERAPIST

Table of content: MR. ADDIS LEE SHEPHERD THERAPIST (NPI 1942783436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942783436 NPI number — MR. ADDIS LEE SHEPHERD THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPHERD
Provider First Name:
ADDIS
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942783436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 WINCHESTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42701-9167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-325-1027
Provider Business Mailing Address Fax Number:
270-765-2557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
THE COMMITMENT HOUSE
Provider Second Line Business Practice Location Address:
115 PARKWAY DRIVE
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42701-7827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-900-0373
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2018

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: 101YM0800X , with the licence number:  275079 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

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




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