Provider Demographics
NPI:1437319712
Name:GILYARD, SHELTON KEITH JR
Entity type:Individual
Prefix:MR
First Name:SHELTON
Middle Name:KEITH
Last Name:GILYARD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 TUCSON CT
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-9315
Mailing Address - Country:US
Mailing Address - Phone:813-684-8906
Mailing Address - Fax:813-974-6115
Practice Address - Street 1:4606 TUCSON CT
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-9315
Practice Address - Country:US
Practice Address - Phone:813-684-8906
Practice Address - Fax:813-974-6115
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities