Provider Demographics
NPI: | 1659443216 |
---|---|
Name: | SCHULTZ, JANICE HAUSER (PSYD, LPC) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JANICE |
Middle Name: | HAUSER |
Last Name: | SCHULTZ |
Suffix: | |
Gender: | F |
Credentials: | PSYD, LPC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1507 WABASH AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | PUEBLO |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 81004-3345 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 719-250-5888 |
Mailing Address - Fax: | 855-775-0361 |
Practice Address - Street 1: | 720 N MAIN ST STE 240 |
Practice Address - Street 2: | |
Practice Address - City: | PUEBLO |
Practice Address - State: | CO |
Practice Address - Zip Code: | 81003-3046 |
Practice Address - Country: | US |
Practice Address - Phone: | 719-250-5888 |
Practice Address - Fax: | 855-775-0361 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-11-15 |
Last Update Date: | 2024-03-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103T00000X | ||
CO | 1421 | 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | |
No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 9000149674 | Medicaid | |
CO | 068103 | Medicaid |