Provider Demographics
NPI:1538758578
Name:SHEPPARD, THERESA MARIE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 100TH TER
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-6767
Mailing Address - Country:US
Mailing Address - Phone:229-237-9191
Mailing Address - Fax:
Practice Address - Street 1:3919 NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4828
Practice Address - Country:US
Practice Address - Phone:352-373-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA95609225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist