Provider Demographics
NPI:1295043750
Name:SCHROEDER, TINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 S MILDRED AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3601
Mailing Address - Country:US
Mailing Address - Phone:352-573-8487
Mailing Address - Fax:
Practice Address - Street 1:1039 S MILDRED AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3601
Practice Address - Country:US
Practice Address - Phone:352-573-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-18
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002543400Medicaid