Provider Demographics
NPI:1407211790
Name:SHELTON, NICOLE (LCAS A)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:LCAS A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 TURNERSBURG HWY
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-2798
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 EXECUTIVE PARK DR.
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1833
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)