Provider Demographics
NPI:1174216758
Name:SHEPPARD, IRINA N
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:N
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 1:64 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9893
Mailing Address - Country:US
Mailing Address - Phone:630-519-1010
Mailing Address - Fax:630-405-7209
Practice Address - Street 1:64 MAIN ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9893
Practice Address - Country:US
Practice Address - Phone:630-519-1010
Practice Address - Fax:630-405-7209
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178018014101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty