Provider Demographics
NPI:1104514447
Name:SHULTZ, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SHULTZ
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 1:2044 1/2 S 12TH ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5054
Mailing Address - Country:US
Mailing Address - Phone:406-550-3638
Mailing Address - Fax:
Practice Address - Street 1:700 SOUTH AVE W STE D
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8011
Practice Address - Country:US
Practice Address - Phone:406-219-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-49329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional