Provider Demographics
NPI:1003953357
Name:SHELTON, MARIE T
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:T
Last Name:SHELTON
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 1:4915 TEXAS HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:BIVINS
Mailing Address - State:TX
Mailing Address - Zip Code:75555-2053
Mailing Address - Country:US
Mailing Address - Phone:903-796-4749
Mailing Address - Fax:
Practice Address - Street 1:4425 JEFFERSON AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1535
Practice Address - Country:US
Practice Address - Phone:870-216-1700
Practice Address - Fax:870-772-5965
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1349C1041C0700X
TX020751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5X821Medicare ID - Type UnspecifiedPART B