Provider Demographics
NPI:1881809119
Name:SCHULTZ, KELLY J (LPC,SAC)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:J
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:LPC,SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-2027
Mailing Address - Country:US
Mailing Address - Phone:715-748-3332
Mailing Address - Fax:715-748-3342
Practice Address - Street 1:540 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-2027
Practice Address - Country:US
Practice Address - Phone:715-748-3332
Practice Address - Fax:715-748-3342
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13934-131101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13934-131OtherSTATE LIC NUMBER
WI43576100Medicaid