Provider Demographics
NPI:1003364969
Name:SHELTON, MARVIN (EDS, EDD, RSAP)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:EDS, EDD, RSAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4166 LINDELL BLVD APT 1B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2923
Mailing Address - Country:US
Mailing Address - Phone:314-580-3029
Mailing Address - Fax:
Practice Address - Street 1:6110 HOWDERSHELL RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1170
Practice Address - Country:US
Practice Address - Phone:314-942-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO9374101YA0400X, 101YP2500X
171M00000X, 261QM0801X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)