Provider Demographics
NPI:1407464894
Name:SHELBY, MICHAEL (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SHELBY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370104
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06137-0104
Mailing Address - Country:US
Mailing Address - Phone:860-796-7151
Mailing Address - Fax:
Practice Address - Street 1:151 NEW PARK AVE UNIT 7
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2191
Practice Address - Country:US
Practice Address - Phone:833-475-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003981101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003981OtherLPC LICENSE