Provider Demographics
NPI:1043761893
Name:SCHULTZ, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3899 W FRONT ST
Mailing Address - Street 2:STE 3
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8104
Mailing Address - Country:US
Mailing Address - Phone:248-634-4424
Mailing Address - Fax:248-634-5995
Practice Address - Street 1:1016 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1379
Practice Address - Country:US
Practice Address - Phone:248-634-4424
Practice Address - Fax:248-634-5995
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
432785585597OtherMICHIGAN DRIVER'S LICENSE
5501017946OtherPHYSICAL THERAPIST LICENSE