Provider Demographics
NPI:1366126674
Name:STEPHENSON, SHEPARD WILEY (LGPC)
Entity type:Individual
Prefix:
First Name:SHEPARD
Middle Name:WILEY
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2514
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-8514
Mailing Address - Country:US
Mailing Address - Phone:301-690-8404
Mailing Address - Fax:
Practice Address - Street 1:23140 MOAKLEY ST STE 6
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2931
Practice Address - Country:US
Practice Address - Phone:301-690-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13630101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor