Provider Demographics
NPI:1154300663
Name:SCHNEIDER, KENNETH R (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:SCHNEIDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3105
Mailing Address - Country:US
Mailing Address - Phone:601-513-4268
Mailing Address - Fax:601-282-5851
Practice Address - Street 1:1820 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3105
Practice Address - Country:US
Practice Address - Phone:601-513-4268
Practice Address - Fax:601-282-5851
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MS29421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS680011364OtherRAILROAD MEDICARE
MS680000183Medicare PIN
MS680011364OtherRAILROAD MEDICARE