Provider Demographics
NPI:1346507910
Name:SCHULTZ, GABRIEL ETHAN (LMP)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ETHAN
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 74TH ST SE APT A
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-6836
Mailing Address - Country:US
Mailing Address - Phone:509-638-4166
Mailing Address - Fax:
Practice Address - Street 1:2020 74TH ST SE APT A
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203
Practice Address - Country:US
Practice Address - Phone:509-638-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60234849225700000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist