Provider Demographics
NPI:1962984799
Name:SCHULTZ, SCOUT
Entity type:Individual
Prefix:
First Name:SCOUT
Middle Name:
Last Name:SCHULTZ
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 1:2204 SAN GABRIEL ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-5063
Mailing Address - Country:US
Mailing Address - Phone:914-602-6743
Mailing Address - Fax:
Practice Address - Street 1:2204 SAN GABRIEL ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-5063
Practice Address - Country:US
Practice Address - Phone:914-602-6743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJXA012549180Medicaid