Provider Demographics
NPI:1285818732
Name:SHULTZ, KENNETH A (EDD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 NE 41ST ST
Mailing Address - Street 2:#310
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6728
Mailing Address - Country:US
Mailing Address - Phone:360-567-1665
Mailing Address - Fax:360-253-3196
Practice Address - Street 1:7600 NE 41ST ST
Practice Address - Street 2:#310
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6728
Practice Address - Country:US
Practice Address - Phone:360-567-1665
Practice Address - Fax:360-253-3196
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY760103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB25690Medicare PIN
WAUPINR11692Medicare UPIN