=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023184694
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON ANTHONY SCHULZ PSY D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 03/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20121 CRAWFORD AVE
-----------------------------------------------------
City | OLYMPIA FIELDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60461-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-756-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35318 EAGLE WAY
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60678-1353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 20042090A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071005343
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------