Provider Demographics
NPI:1790845162
Name:SHELTON THOMAS, MARGERY LOUISE (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARGERY
Middle Name:LOUISE
Last Name:SHELTON THOMAS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 N LARCHMONT BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3754
Mailing Address - Country:US
Mailing Address - Phone:323-957-3702
Mailing Address - Fax:323-463-4489
Practice Address - Street 1:252 N LARCHMONT BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3754
Practice Address - Country:US
Practice Address - Phone:323-957-3702
Practice Address - Fax:323-463-4489
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS95811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS9581OtherSTATE LICENSE
CASW9581Medicare ID - Type Unspecified