1619051067 NPI number — MRS. SUZANNE LOUISA SHELTON BSW

Table of content: MRS. SUZANNE LOUISA SHELTON BSW (NPI 1619051067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619051067 NPI number — MRS. SUZANNE LOUISA SHELTON BSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELTON
Provider First Name:
SUZANNE
Provider Middle Name:
LOUISA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHARPE
Provider Other First Name:
SUZANNE
Provider Other Middle Name:
LOUISA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619051067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8451 SARTORI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLINGTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-829-6466
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3810 WINCHESTER RD
Provider Second Line Business Practice Location Address:
SOUTHEAST MENTAL HEALTH CENTER
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38118-9007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-369-1420
Provider Business Practice Location Address Fax Number:
901-369-1433
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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