Provider Demographics
NPI:1407528904
Name:SHULTZ, TOVA WILLET (CO61186739)
Entity Type:Individual
Prefix:
First Name:TOVA
Middle Name:WILLET
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:CO61186739
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18818 E MARLIN DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99027-9560
Mailing Address - Country:US
Mailing Address - Phone:509-904-3750
Mailing Address - Fax:
Practice Address - Street 1:1302 W GARDNER AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2059
Practice Address - Country:US
Practice Address - Phone:509-904-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61186739251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health