Provider Demographics
NPI:1023104064
Name:SCHULTZ, ERIC E (LCSW)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:E
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2719
Mailing Address - Country:US
Mailing Address - Phone:217-224-4453
Mailing Address - Fax:217-224-9383
Practice Address - Street 1:927 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2719
Practice Address - Country:US
Practice Address - Phone:217-224-4453
Practice Address - Fax:217-224-9383
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0053161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL732001OtherBLUE CROSS BLUE SHIELD
IL732001OtherBLUE CROSS BLUE SHIELD
202654Medicare PIN