Provider Demographics
NPI:1720176860
Name:SCHULTZ, CONNIE ANN (MS, LICSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANN
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:MS, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12533 355TH ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MN
Mailing Address - Zip Code:56310-8736
Mailing Address - Country:US
Mailing Address - Phone:320-363-8877
Mailing Address - Fax:320-363-8821
Practice Address - Street 1:12533 355TH ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:MN
Practice Address - Zip Code:56310-8736
Practice Address - Country:US
Practice Address - Phone:320-363-8877
Practice Address - Fax:320-363-8821
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6485LICSW104100000X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN434M1SCOtherBLUE CROSS BLUE SHIELD
MN434M2SCOtherBLUE CROSS BLUE SHIELD
MNHP27100OtherHEALTH PARTNERS
MN6203572OtherMEDICA/UBH