Healthcare Provider Details

I. General information

NPI: 1700544335
Provider Name (Legal Business Name): TERRY LEE SHULTZ M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TERRY LEE SHULTZ LPC

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 CATO AVE
STATE COLLEGE PA
16801-2765
US

IV. Provider business mailing address

413 DOUGLAS DR
STATE COLLEGE PA
16803-1536
US

V. Phone/Fax

Practice location:
  • Phone: 814-308-8375
  • Fax: 814-308-8126
Mailing address:
  • Phone: 814-441-4508
  • Fax: 814-308-8126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC013978
License Number StatePA

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: