Provider Demographics
NPI:1982684304
Name:SCHULTZ, MARIAN R (MSW)
Entity Type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:R
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 CORNWALL AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4642
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:360-671-3754
Practice Address - Street 1:6060 PORTAL WAY
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-7833
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:360-671-3574
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004371101YM0800X, 1041C0700X
IL149.012346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002788200Medicaid
IL2233222OtherBLUE CROSS BLUE SHIELD
ID000010016208OtherREGENCE BCBS
ID000010016208OtherREGENCE BCBS
IL215480Medicare PIN