Provider Demographics
NPI:1740695881
Name:SCHULTZ, KATHLEEEN
Entity type:Individual
Prefix:
First Name:KATHLEEEN
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10169 KARSTON CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4610
Mailing Address - Country:US
Mailing Address - Phone:763-226-6922
Mailing Address - Fax:
Practice Address - Street 1:10169 KARSTON CT NE
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4610
Practice Address - Country:US
Practice Address - Phone:763-226-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301799101YA0400X
MN199251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301799OtherMINNESOTA LICENSE
MN19925OtherMINNESOTA LICENSE