Healthcare Provider Details

I. General information

NPI: 1629648407
Provider Name (Legal Business Name): MARY KAY SHELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16600 W SPRAGUE RD
CLEVELAND OH
44130-6318
US

IV. Provider business mailing address

1578 HOPKINS AVE
LAKEWOOD OH
44107-5037
US

V. Phone/Fax

Practice location:
  • Phone: 440-523-0370
  • Fax:
Mailing address:
  • Phone: 440-708-8922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: