Basic Information
| Provider Information | |||||||||
| NPI: | 1235346362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHULTZ | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2130 N 20TH ST | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530812213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204537049 | ||||||||
| FaxNumber: | 9204594341 | ||||||||
| Practice Location | |||||||||
| Address1: | 3014 ERIE AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530813658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204537049 | ||||||||
| FaxNumber: | 9204594341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1801968847 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 118-027 | 01 | WI | CERIFIED OT ASSISTANT | OTHER |