Provider Demographics
NPI:1801566633
Name:SHULTZ, ERIC (PTA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 RAINBOW DR # 4875
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77399-1048
Mailing Address - Country:US
Mailing Address - Phone:509-581-9656
Mailing Address - Fax:
Practice Address - Street 1:55 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-3723
Practice Address - Country:US
Practice Address - Phone:928-282-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA-014351225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty