Healthcare Provider Details

I. General information

NPI: 1003364969
Provider Name (Legal Business Name): MARVIN SHELTON ED.S, ED.D, RSAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 HOWDERSHELL RD
HAZELWOOD MO
63042-1170
US

IV. Provider business mailing address

4166 LINDELL BLVD APT 1B
SAINT LOUIS MO
63108-2923
US

V. Phone/Fax

Practice location:
  • Phone: 314-942-9499
  • Fax:
Mailing address:
  • Phone: 314-580-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9374
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9374
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: