Provider Demographics
NPI:1841367372
Name:SHULTZ, CONRAD (LADC)
Entity type:Individual
Prefix:
First Name:CONRAD
Middle Name:
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ANNASNAPPITT DR
Mailing Address - Street 2:
Mailing Address - City:PLYMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:02367-1718
Mailing Address - Country:US
Mailing Address - Phone:781-585-3155
Mailing Address - Fax:
Practice Address - Street 1:2 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3964
Practice Address - Country:US
Practice Address - Phone:508-830-1234
Practice Address - Fax:508-830-1191
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA967101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)