Basic Information
| Provider Information | |||||||||
| NPI: | 1023274388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPARD | ||||||||
| FirstName: | BLAIR | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 LUNA ST SE | ||||||||
| Address2: | |||||||||
| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870319277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055651619 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5312 JAGUAR DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875071827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058200262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0121891 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 0119171 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.