=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891946851
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZZETTE M SHELTON L.C.D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 10/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8509 WESTERN HILLS BOULEVARD SUITE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76108-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-875-6219
-----------------------------------------------------
Fax | 817-336-4663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8509 WESTERN HILLS BLVD SUITE 200
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76108-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-875-6219
-----------------------------------------------------
Fax | 817-336-4663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 3523
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 221496
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------