Provider Demographics
NPI:1033153242
Name:SHELTON, JOHN LEWIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEWIS
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-0744
Mailing Address - Country:US
Mailing Address - Phone:360-321-1022
Mailing Address - Fax:360-321-4575
Practice Address - Street 1:3331 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4472
Practice Address - Country:US
Practice Address - Phone:360-321-1022
Practice Address - Fax:360-321-4575
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000580103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0017234OtherWASHINGTON STATE DEPARTMENT OF LABOR AND INDUSTRIES
WAPY00000580OtherPROFESSIONAL LICENSE
WAG8878510Medicare PIN