=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821602863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA SCHULTZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2020
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 5TH ST S STE 206
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-593-1736
-----------------------------------------------------
Fax | 218-520-0700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 5TH ST S STE 206
-----------------------------------------------------
City | MOORHEAD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56560-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-593-1736
-----------------------------------------------------
Fax | 218-520-0700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 3684
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------