Provider Demographics
NPI:1275644882
Name:SCHROEDER, DAVID G (PHD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:G
Last Name:SCHROEDER
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 1:60 ELM ST
Mailing Address - Street 2:
Mailing Address - City:VERNON ROCKVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3240
Mailing Address - Country:US
Mailing Address - Phone:860-875-0292
Mailing Address - Fax:860-871-4910
Practice Address - Street 1:60 ELM ST
Practice Address - Street 2:
Practice Address - City:VERNON ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-3240
Practice Address - Country:US
Practice Address - Phone:860-875-0292
Practice Address - Fax:860-871-4910
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001080103T00000X
CT00106106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060001080CT02OtherBLUE CROSS, BLUE SHIELD