Provider Demographics
NPI:1902414162
Name:SHELTON, NICOLETTE R (CDCA,QMHS)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:R
Last Name:SHELTON
Suffix:
Gender:F
Credentials:CDCA,QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619-1134
Mailing Address - Country:US
Mailing Address - Phone:740-451-0342
Mailing Address - Fax:
Practice Address - Street 1:103 2ND AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1134
Practice Address - Country:US
Practice Address - Phone:740-451-7627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.174960171M00000X
OHCDCA.178713101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0423675Medicaid