Provider Demographics
NPI:1588017115
Name:SHELTON, BERNICE (DT)
Entity Type:Individual
Prefix:MRS
First Name:BERNICE
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 STONEY ISLAND AVE
Mailing Address - Street 2:P.O. BOX 2510
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-1726
Mailing Address - Country:US
Mailing Address - Phone:773-339-1867
Mailing Address - Fax:708-868-1290
Practice Address - Street 1:450 PRAIRIE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2125
Practice Address - Country:US
Practice Address - Phone:773-339-1867
Practice Address - Fax:708-868-1290
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency