Provider Demographics
NPI:1891588174
Name:SHEPHERD, PAYTON
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:SHEPHERD
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 1:1969 HERITAGE FARMS DR
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069-3624
Mailing Address - Country:US
Mailing Address - Phone:314-852-0773
Mailing Address - Fax:
Practice Address - Street 1:214 N CLAY AVE STE 215
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4068
Practice Address - Country:US
Practice Address - Phone:314-852-0773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022029630101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health