Provider Demographics
NPI:1194543132
Name:SHELTON, DAVID LEWIS (LMFT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LEWIS
Last Name:SHELTON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9458 CREEKSTONE CT
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3376
Mailing Address - Country:US
Mailing Address - Phone:770-833-1234
Mailing Address - Fax:
Practice Address - Street 1:400 TECHNOLOGY CT SE STE J
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5237
Practice Address - Country:US
Practice Address - Phone:770-431-2354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT002136106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health