Basic Information
| Provider Information | |||||||||
| NPI: | 1467758094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHULTZ | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSSA, LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24531 WILDWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441454971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404659059 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3518 W 25TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167412241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2011 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.0800268-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0268768 | 05 | OH | MEDICAID |