Provider Demographics
NPI:1932797941
Name:SHEPARD, NICKY (MS)
Entity type:Individual
Prefix:
First Name:NICKY
Middle Name:
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5440
Mailing Address - Country:US
Mailing Address - Phone:406-250-0534
Mailing Address - Fax:
Practice Address - Street 1:919 3RD AVE E
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5440
Practice Address - Country:US
Practice Address - Phone:406-250-0534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT109738103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool