Provider Demographics
NPI:1093412108
Name:SCHULTZ, MCKENZIE MYA
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:MYA
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 1:2720 S HIGHLAND AVE APT 417
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5393
Mailing Address - Country:US
Mailing Address - Phone:815-412-4280
Mailing Address - Fax:
Practice Address - Street 1:25012 104TH AVE SE STE C
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-2821
Practice Address - Country:US
Practice Address - Phone:253-499-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008915225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILEAV826943729OtherBCBS