Provider Demographics
NPI:1679152441
Name:SHELTON, SHONNELL
Entity Type:Individual
Prefix:
First Name:SHONNELL
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13603 AVEBURY DR APT 12
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3439
Mailing Address - Country:US
Mailing Address - Phone:240-918-0861
Mailing Address - Fax:
Practice Address - Street 1:9811 MALLARD DR STE 203
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3199
Practice Address - Country:US
Practice Address - Phone:301-778-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
DCLG50081504104100000X
MD21094104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker