Provider Demographics
NPI:1063420545
Name:SHEPARD, LISA J (DPT, OCS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1294 WEST 6TH STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2997
Mailing Address - Country:US
Mailing Address - Phone:310-547-1850
Mailing Address - Fax:310-547-1972
Practice Address - Street 1:1294 WEST 6TH STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2997
Practice Address - Country:US
Practice Address - Phone:310-547-1850
Practice Address - Fax:310-547-1972
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT26466Medicare UPIN
CAW15555Medicare ID - Type UnspecifiedMEDICARE PROVIDER