Provider Demographics
NPI:1679621254
Name:SHEPHERD, KEVIN L (PT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12197 S DRAPER GATE DR STE B
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8078
Mailing Address - Country:US
Mailing Address - Phone:801-523-3415
Mailing Address - Fax:801-523-1843
Practice Address - Street 1:12197 S DRAPER GATE DR STE B
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8078
Practice Address - Country:US
Practice Address - Phone:801-523-3415
Practice Address - Fax:801-523-1843
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9011965924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000006694Medicare PIN
UT466515Medicare ID - Type UnspecifiedMEDICARE