Provider Demographics
NPI:1346429164
Name:SHELTON, TREAVOR
Entity Type:Individual
Prefix:
First Name:TREAVOR
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E 3RD ST APT 302
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1464
Mailing Address - Country:US
Mailing Address - Phone:310-702-4520
Mailing Address - Fax:
Practice Address - Street 1:1704 W MANCHESTER AVE STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3056
Practice Address - Country:US
Practice Address - Phone:310-702-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)