Healthcare Provider Details

I. General information

NPI: 1063321016
Provider Name (Legal Business Name): BYRON MACK SHELTON MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27884 JOHN F KENNEDY DR UNIT B
MORENO VALLEY CA
92555-5861
US

IV. Provider business mailing address

27884 JOHN F KENNEDY DR UNIT B
MORENO VALLEY CA
92555-5861
US

V. Phone/Fax

Practice location:
  • Phone: 951-796-4105
  • Fax:
Mailing address:
  • Phone: 951-796-4105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number139907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: