Provider Demographics
NPI:1154402329
Name:SHEPPARD, THOMAS JOHN (PT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:SHEPPARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:23655 NOVI RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-5442
Practice Address - Country:US
Practice Address - Phone:248-277-3440
Practice Address - Fax:248-277-3441
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F333630OtherBLUE CROSS BLUE SHIELD
MIQ26462040Medicare ID - Type Unspecified