Provider Demographics
NPI:1568883163
Name:SHELTON, GWENDOLYN A (LCSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:A
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 1:280 CUMBERLAND TRACE RD
Mailing Address - Street 2:APT. 325
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-9099
Mailing Address - Country:US
Mailing Address - Phone:270-929-3386
Mailing Address - Fax:
Practice Address - Street 1:1215 HIGH ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2541
Practice Address - Country:US
Practice Address - Phone:270-782-1116
Practice Address - Fax:270-782-9108
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical