Healthcare Provider Details

I. General information

NPI: 1467651000
Provider Name (Legal Business Name): MARY W SCHULTZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY W LONG

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST
PATCHOGUE NY
11772
US

IV. Provider business mailing address

PO BOX 249
BELLPORT NY
11713
US

V. Phone/Fax

Practice location:
  • Phone: 631-880-1147
  • Fax:
Mailing address:
  • Phone: 631-880-1147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number016959
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: