Provider Demographics
NPI:1992141345
Name:SHEPHERD, CHARLES (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SHEPHERD
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 1:3310 PROFESSIONAL PARK STE 102
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-689-2341
Mailing Address - Fax:270-689-2342
Practice Address - Street 1:3310 PROFESSIONAL PARK STE 102
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-689-2341
Practice Address - Fax:270-689-2342
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist