Provider Demographics
NPI:1215947528
Name:SHELTON, MARK D (LICSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:SHELTON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:SOCIAL SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7990
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:SOCIAL SERVICES
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7990
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111762104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0300010Medicaid
MA99622101OtherNETWORK HEALTH
MA1001250OtherGROUP
MA1300709Medicaid
MA1001250OtherGROUP
MAY10141Medicare ID - Type UnspecifiedPART B-GROUP
MA221804Medicare ID - Type UnspecifiedPARTA-GROUP
MAY10141Medicare ID - Type UnspecifiedPART B
MA99622101OtherNETWORK HEALTH