Provider Demographics
NPI:1487892014
Name:SHELTON, VIVIAN ALLISON (PSYD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:ALLISON
Last Name:SHELTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6723 WHITTIER AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4522
Mailing Address - Country:US
Mailing Address - Phone:703-475-6478
Mailing Address - Fax:
Practice Address - Street 1:6723 WHITTIER AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4522
Practice Address - Country:US
Practice Address - Phone:703-475-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8990103TC0700X
VA0810003370103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1487892014OtherTUFTS
001065301OtherMEDICARE
MA213380OtherNEIGHBORHOOD HEALTH
MA1487892014OtherBLUE SHIELD
6901895/5887718OtherAETNA