Provider Demographics
NPI:1285475103
Name:SCHULTZ, ETHAN (DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017C PARKSIDE AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-8979
Mailing Address - Country:US
Mailing Address - Phone:320-894-0664
Mailing Address - Fax:
Practice Address - Street 1:2815 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-745-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16813-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty