Provider Demographics
NPI:1972640936
Name:SCHELTON, HENRY (LISW)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:SCHELTON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CIENEGA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9117
Mailing Address - Country:US
Mailing Address - Phone:505-867-4321
Mailing Address - Fax:
Practice Address - Street 1:301 LOMA COLORADO ST NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6562
Practice Address - Country:US
Practice Address - Phone:505-896-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI- 37421041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75461Medicaid