Provider Demographics
NPI:1366266041
Name:SHEPPARD, SAMANTHA KATHLEEN (MA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KATHLEEN
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 N CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:NEW LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45345-9641
Mailing Address - Country:US
Mailing Address - Phone:937-248-4100
Mailing Address - Fax:
Practice Address - Street 1:600 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1944
Practice Address - Country:US
Practice Address - Phone:937-548-6842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional