Provider Demographics
NPI:1164291738
Name:SHELTON, BRANDIE (BT)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 MS KELLY RD
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542-7802
Mailing Address - Country:US
Mailing Address - Phone:252-315-8418
Mailing Address - Fax:
Practice Address - Street 1:13393 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:ARCHER LODGE
Practice Address - State:NC
Practice Address - Zip Code:27527-6998
Practice Address - Country:US
Practice Address - Phone:252-315-8418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBACB967818106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician