Provider Demographics
NPI:1568444776
Name:KENNETH A SHULTZ EDD PS
Entity Type:Organization
Organization Name:KENNETH A SHULTZ EDD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:360-567-1665
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY760103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB25691Medicare PIN
R11692Medicare UPIN