Provider Demographics
NPI:1801204664
Name:STULTZ, ANNA MARIE (CDCA, QMHS)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:STULTZ
Suffix:
Gender:F
Credentials:CDCA, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7838
Mailing Address - Country:US
Mailing Address - Phone:740-656-3248
Mailing Address - Fax:
Practice Address - Street 1:126 E 2ND ST STE 3
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2593
Practice Address - Country:US
Practice Address - Phone:740-851-5307
Practice Address - Fax:740-851-5307
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162971101YA0400X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3103402OtherPROVIDER NUMBER