Provider Demographics
NPI:1043835440
Name:SHOULTZ, MICHAEL DALE (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALE
Last Name:SHOULTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 N LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1132
Mailing Address - Country:US
Mailing Address - Phone:608-345-8277
Mailing Address - Fax:
Practice Address - Street 1:2622 HOARD ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4827
Practice Address - Country:US
Practice Address - Phone:608-345-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI137960174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty