Provider Demographics
NPI:1558691279
Name:SHULTZ, MONTY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MONTY
Middle Name:
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E ELK TRL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-8337
Mailing Address - Country:US
Mailing Address - Phone:308-627-6119
Mailing Address - Fax:
Practice Address - Street 1:141 S MCCORMICK ST STE 100
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4730
Practice Address - Country:US
Practice Address - Phone:308-627-4743
Practice Address - Fax:928-852-0804
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE90581041C0700X, 1041C0700X
AZ213341041C0700X
NE1219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ21943OtherLICENSED PROFESSIONAL COUNSELOR
AZ133519Medicaid
NE1219OtherLICENSED INDEPENDENT MENTAL HEALTH PRACTITIONER
NE10026398900Medicaid
AZ21334OtherLICENSED CLINICAL SOCIAL WORKER
NE1423OtherMASTER SOCIAL WORKER
NE3971OtherMENTAL HEALTH PRACTITIONER