MEDICARE: MISS NATASHIA SHANTAL SHELLEY LPCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A10070	NC

General Provider Information

NPI Number	:	1497158661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NATASHIA SHANTAL SHELLEY LPCA

Provider Business Mailing Address
First Line	:	3620 TROTTERS DR W
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27893-8343
Country	:	US
Telephone Number	:	252-245-0042
Fax Number	:

Provider Business Practice Location Address
First Line	:	4805 GREEN RD
Second Line	:	SUITE 103
City	:	RALEIGH
State	:	NC
Zip	:	27616-2848
Country	:	US
Telephone Number	:	919-872-6220
Fax Number	:	919-876-6223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	10/02/2014

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