Provider Demographics
NPI:1902552417
Name:SCHULTZ, BROCK DAVIS VERN (LPC-IT)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:DAVIS VERN
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 W BROADWAY STE 104
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3700
Mailing Address - Country:US
Mailing Address - Phone:608-395-1795
Mailing Address - Fax:
Practice Address - Street 1:1955 W BROADWAY STE 104
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53713-3700
Practice Address - Country:US
Practice Address - Phone:608-395-1795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3887-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional