Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 9374 | MO |
N | 101YP2500X | Professional Counselor | 9374 | MO |
NPI | 1003364969 |
---|---|
Provider Name | Dr. Marvin Shelton |
First Address | Saint Louis, MO 63108-2923 |
Second Address | Hazelwood, MO 63042-1170 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2016 |
Last Update Date | 19/09/2019 |