Provider Demographics
NPI:1629406509
Name:SHELTON, GWEN ROCHELLE
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:ROCHELLE
Last Name:SHELTON
Suffix:
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 1:1302 BUCKHANNON PIKE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4406
Mailing Address - Country:US
Mailing Address - Phone:304-326-7532
Mailing Address - Fax:
Practice Address - Street 1:445 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2843
Practice Address - Country:US
Practice Address - Phone:304-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
WV1475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist