Provider Demographics
NPI:1205389855
Name:SHELTON, KELSEY RAE (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:RAE
Last Name:SHELTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:KELSEY
Other - Middle Name:RAE
Other - Last Name:SWEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:3510 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1747
Mailing Address - Country:US
Mailing Address - Phone:859-462-0066
Mailing Address - Fax:
Practice Address - Street 1:1155 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2542
Practice Address - Country:US
Practice Address - Phone:859-462-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0192431Medicaid