Provider Demographics
NPI:1154489417
Name:SCHRODER, MARK RICHARD (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:SCHRODER
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 MACK ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5130
Mailing Address - Country:US
Mailing Address - Phone:513-874-4530
Mailing Address - Fax:513-346-3811
Practice Address - Street 1:2810 MACK ROAD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5130
Practice Address - Country:US
Practice Address - Phone:513-874-4530
Practice Address - Fax:513-346-3811
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000020680OtherANTHEM
OH07 239 039OtherPCN
OH07 239 039OtherPCN