Provider Demographics
NPI:1114351400
Name:SHULTS, ERIC MICHAEL (MS, BCBA)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MICHAEL
Last Name:SHULTS
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11286 S 200TH ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-4541
Mailing Address - Country:US
Mailing Address - Phone:678-738-3077
Mailing Address - Fax:
Practice Address - Street 1:16380 ROSCOE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1221
Practice Address - Country:US
Practice Address - Phone:818-791-4387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH006165103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003235329AMedicaid
1-02-1037OtherBCBA CERTIFICATE