Provider Demographics
NPI:1164259693
Name:SHELTON, LORIE WAGNER (BA, MA)
Entity type:Individual
Prefix:MRS
First Name:LORIE
Middle Name:WAGNER
Last Name:SHELTON
Suffix:
Gender:F
Credentials:BA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7165 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-8417
Mailing Address - Country:US
Mailing Address - Phone:336-406-8031
Mailing Address - Fax:
Practice Address - Street 1:7165 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:PFAFFTOWN
Practice Address - State:NC
Practice Address - Zip Code:27040-8417
Practice Address - Country:US
Practice Address - Phone:336-406-8031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0661101YM0800X
NCA20556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health