Provider Demographics
NPI:1770828998
Name:SHELTON, KANTRELL DESHAWN (LCAS)
Entity type:Individual
Prefix:MR
First Name:KANTRELL
Middle Name:DESHAWN
Last Name:SHELTON
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 DALMATION DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-4004
Mailing Address - Country:US
Mailing Address - Phone:910-263-9570
Mailing Address - Fax:
Practice Address - Street 1:112 E ELWOOD AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2921
Practice Address - Country:US
Practice Address - Phone:910-848-1924
Practice Address - Fax:910-848-1928
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3029A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)