Provider Demographics
NPI:1821602863
Name:SCHULTZ, ALYSSA
Entity type:Individual
Prefix:
First Name:ALYSSA
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 1:200 5TH ST S STE 206
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2768
Mailing Address - Country:US
Mailing Address - Phone:218-593-1736
Mailing Address - Fax:218-520-0700
Practice Address - Street 1:200 5TH ST S STE 206
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2768
Practice Address - Country:US
Practice Address - Phone:218-593-1736
Practice Address - Fax:218-520-0700
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
EINOther92-3295221