Provider Demographics
NPI:1891239323
Name:SHELTON, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
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 1:6745 HASKELL AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-6155
Mailing Address - Country:US
Mailing Address - Phone:818-441-9377
Mailing Address - Fax:
Practice Address - Street 1:6745 HASKELL AVE
Practice Address - Street 2:APT 4
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-6155
Practice Address - Country:US
Practice Address - Phone:818-441-9377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12966225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist