Provider Demographics
NPI:1265180970
Name:SHOULTZ, SUSAN MARIE (LCMT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:SHOULTZ
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14440 28TH PL N STE 200
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4854
Mailing Address - Country:US
Mailing Address - Phone:321-772-8226
Mailing Address - Fax:
Practice Address - Street 1:5315 LYNDALE AVE S STE A
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1285
Practice Address - Country:US
Practice Address - Phone:612-223-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN374J00000X
IL227-016917225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoula