Healthcare Provider Details

I. General information

NPI: 1871001362
Provider Name (Legal Business Name): DERICK SCHULTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 SAN JACINTO RIVER RD STE 107
LAKE ELSINORE CA
92530-4400
US

IV. Provider business mailing address

265 SAN JACINTO RIVER RD STE 107
LAKE ELSINORE CA
92530-4400
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-9243
  • Fax: 951-674-9635
Mailing address:
  • Phone: 951-674-9243
  • Fax: 951-674-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: