Healthcare Provider Details

I. General information

NPI: 1063983336
Provider Name (Legal Business Name): M KIVAUGHN SHELTON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 N VAN NESS AVE
FRESNO CA
93728-3419
US

IV. Provider business mailing address

539 N VAN NESS AVE
FRESNO CA
93728-3419
US

V. Phone/Fax

Practice location:
  • Phone: 559-266-9581
  • Fax: 559-498-0507
Mailing address:
  • Phone: 559-266-9581
  • Fax: 559-498-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR8522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: