Provider Demographics
NPI:1790466423
Name:SHELTON, KOKETTA
Entity Type:Individual
Prefix:
First Name:KOKETTA
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 1:3041 BERKS WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614
Mailing Address - Country:US
Mailing Address - Phone:919-283-6083
Mailing Address - Fax:
Practice Address - Street 1:3041 BERKS WAY STE 102C
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6777
Practice Address - Country:US
Practice Address - Phone:919-283-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP019434101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty