Provider Demographics
NPI:1265456784
Name:SCHULTZ, KENNETH DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:K.
Other - Middle Name:DAVID
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:15 LAUREL WOODS RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-2516
Mailing Address - Country:US
Mailing Address - Phone:203-263-0290
Mailing Address - Fax:203-263-0290
Practice Address - Street 1:15 LAUREL WOODS RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-2516
Practice Address - Country:US
Practice Address - Phone:203-263-0290
Practice Address - Fax:203-263-0290
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical