Basic Information
| Provider Information | |||||||||
| NPI: | 1780034975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHULTZE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | WARREN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 E MINARETS AVE | ||||||||
| Address2: | |||||||||
| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936501239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553431057 | ||||||||
| FaxNumber: | 8445876405 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 E MINARETS AVE | ||||||||
| Address2: | |||||||||
| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936501239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553431057 | ||||||||
| FaxNumber: | 8445876405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2016 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF89178 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1013030808 | 05 | CA | MEDICAID |