Provider Demographics
NPI:1215085444
Name:SHEPHARD, THERESA MARY (RN)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARY
Last Name:SHEPHARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8122 BRICKER RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48006-1301
Mailing Address - Country:US
Mailing Address - Phone:810-387-9712
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-2505
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704160329163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)