Healthcare Provider Details

I. General information

NPI: 1609515840
Provider Name (Legal Business Name): SHARIDYN KELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 BANDIT TRL
KELLER TX
76248-0111
US

IV. Provider business mailing address

773 BANDIT TRL
KELLER TX
76248-0111
US

V. Phone/Fax

Practice location:
  • Phone: 817-984-8655
  • Fax:
Mailing address:
  • Phone: 817-984-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-140860
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: