Healthcare Provider Details

I. General information

NPI: 1164369476
Provider Name (Legal Business Name): DESIRE SHELTON
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: DESIRE NICOLE SHELTON

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 HIGHLAND DR APT 103
GLEN BURNIE MD
21061-8960
US

IV. Provider business mailing address

312 HIGHLAND DR APT 103
GLEN BURNIE MD
21061-8960
US

V. Phone/Fax

Practice location:
  • Phone: 240-814-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: