Provider Demographics
NPI:1922018621
Name:SHELTON, BRUCE B (LCSW, CSAC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:B
Last Name:SHELTON
Suffix:
Gender:M
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 1711
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3167
Mailing Address - Country:US
Mailing Address - Phone:757-428-7500
Mailing Address - Fax:757-428-7699
Practice Address - Street 1:921 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 1711
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3167
Practice Address - Country:US
Practice Address - Phone:757-428-7500
Practice Address - Fax:757-428-7699
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040050971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010187991Medicaid
VA018560F27Medicare PIN
Q21796Medicare UPIN
VA190001307Medicare ID - Type Unspecified