Provider Demographics
NPI:1104090745
Name:SHELTON, LISA PATRICE (MS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:PATRICE
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:P
Other - Last Name:SHELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LCPC, CAADC
Mailing Address - Street 1:132 QUEENSBERRY CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4899
Mailing Address - Country:US
Mailing Address - Phone:224-735-1210
Mailing Address - Fax:
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1534
Practice Address - Country:US
Practice Address - Phone:336-770-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17438101YA0400X
NC25760101YA0400X, 101YA0400X
NC15221101YM0800X
IL180.008438101YP2500X, 106H00000X, 101YP2500X
NCS15221101YM0800X
WI13583 - 132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39168700Medicaid