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General NPI Number Information
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NPI Number | 1164206512
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Entity Type | Individual
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Provider Name | CRYSTAL ANN SHULDA LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/24/2023
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 101 CHITTYVILLE RD
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City | HERRIN
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State | IL
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Zip | 62948-3552
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Country | US
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Telephone | 618-498-0190
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Fax | 618-417-6049
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Provider Business Mailing Address
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Address Line | 412 FARRIS ST
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City | CARTERVILLE
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State | IL
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Zip | 62918-1177
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Country | US
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Telephone | 618-713-7685
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | IL
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