Provider Demographics
NPI:1477064236
Name:SHELTON, SAMUEL EDWARD
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:EDWARD
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 1:817 238TH ST SE STE H
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4309
Mailing Address - Country:US
Mailing Address - Phone:425-820-4717
Mailing Address - Fax:
Practice Address - Street 1:817 238TH ST SE STE H
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4309
Practice Address - Country:US
Practice Address - Phone:425-820-4717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW610961581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASC60701093OtherLSWAIC