Provider Demographics
NPI:1194181008
Name:SHELTON, MARY ANN (LMBT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:SHELTON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 BOEYKENS PL
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2152
Mailing Address - Country:US
Mailing Address - Phone:309-310-9730
Mailing Address - Fax:
Practice Address - Street 1:112 BOEYKENS PL
Practice Address - Street 2:SUITE 3E
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2152
Practice Address - Country:US
Practice Address - Phone:309-310-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227017812225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist