Provider Demographics
NPI:1962991711
Name:SHEPHERD, TONYA (MHS)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 JUNIPTER CIRCLE
Mailing Address - Street 2:
Mailing Address - City:IOWA
Mailing Address - State:LA
Mailing Address - Zip Code:70647
Mailing Address - Country:US
Mailing Address - Phone:337-602-6391
Mailing Address - Fax:337-602-6392
Practice Address - Street 1:1639 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5948
Practice Address - Country:US
Practice Address - Phone:337-602-6391
Practice Address - Fax:337-602-6392
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA007435213171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA007435213Medicaid