Provider Demographics
NPI:1669200994
Name:SHEPARD, MARLO GAZZO (LMFT)
Entity type:Individual
Prefix:
First Name:MARLO
Middle Name:GAZZO
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:LMFT
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 87
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:71264-0087
Mailing Address - Country:US
Mailing Address - Phone:318-381-7713
Mailing Address - Fax:
Practice Address - Street 1:107 HOLLY STREET
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:LA
Practice Address - Zip Code:71264
Practice Address - Country:US
Practice Address - Phone:318-381-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0494106H00000X
LAMFT1340106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist