Provider Demographics
NPI:1699276709
Name:SHEPHERD, KELSEY (LSW, LICDC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:LSW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3938 ROSEMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5057
Mailing Address - Country:US
Mailing Address - Phone:740-978-0348
Mailing Address - Fax:
Practice Address - Street 1:400 E STATE ST STE D
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1870
Practice Address - Country:US
Practice Address - Phone:740-326-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2207753104100000X
OHLICDC.162651101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)