Provider Demographics
NPI:1104707306
Name:SCHULTZ, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 TAMARACK DR W
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3622
Mailing Address - Country:US
Mailing Address - Phone:608-235-3612
Mailing Address - Fax:
Practice Address - Street 1:1317 W GRAND AVE STE 6
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2075
Practice Address - Country:US
Practice Address - Phone:262-427-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12060-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional