Provider Demographics
NPI:1629122908
Name:SHILTZ, THOMAS J (LPC CADC III)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:SHILTZ
Suffix:
Gender:M
Credentials:LPC CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W62N248 WASHINGTON AVENUE
Mailing Address - Street 2:SUITE #207
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012
Mailing Address - Country:US
Mailing Address - Phone:262-375-1116
Mailing Address - Fax:262-375-1071
Practice Address - Street 1:W62N248 WASHINGTON AVENUE
Practice Address - Street 2:SUITE #207
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012
Practice Address - Country:US
Practice Address - Phone:262-375-1116
Practice Address - Fax:262-375-1071
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2695125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40967400Medicaid