Provider Demographics
NPI:1275072308
Name:SHELTON, STEPHANIE MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:SHELTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 NEOSHO ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2542
Mailing Address - Country:US
Mailing Address - Phone:708-802-3618
Mailing Address - Fax:
Practice Address - Street 1:434 NEOSHO ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2542
Practice Address - Country:US
Practice Address - Phone:708-802-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0189121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical