Healthcare Provider Details

I. General information

NPI: 1891946851
Provider Name (Legal Business Name): SUZZETTE M SHELTON L.C.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8509 WESTERN HILLS BOULEVARD SUITE 200
FORT WORTH TX
76108-3410
US

IV. Provider business mailing address

8509 WESTERN HILLS BLVD SUITE 200
FORT WORTH TX
76108-3410
US

V. Phone/Fax

Practice location:
  • Phone: 817-875-6219
  • Fax: 817-336-4663
Mailing address:
  • Phone: 817-875-6219
  • Fax: 817-336-4663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3523
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number221496
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: