Provider Demographics
NPI:1124541537
Name:SHEPPARD, SAM A (PT, DPT)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:A
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 RIVER LANDING DR UNIT 101A
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8612
Mailing Address - Country:US
Mailing Address - Phone:843-834-6406
Mailing Address - Fax:
Practice Address - Street 1:145 RIVER LANDING DR UNIT 101A
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-8612
Practice Address - Country:US
Practice Address - Phone:843-834-6406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040635225100000X
SC10325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC10325OtherSC STATE LICENSE