Provider Demographics
NPI:1437539194
Name:SCHROEDER, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:804 W. CHOCTAW
Mailing Address - Street 2:
Mailing Address - City:CHICKASAH
Mailing Address - State:OK
Mailing Address - Zip Code:73108
Mailing Address - Country:US
Mailing Address - Phone:405-222-0622
Mailing Address - Fax:
Practice Address - Street 1:807 SW F AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4506
Practice Address - Country:US
Practice Address - Phone:580-595-7000
Practice Address - Fax:580-595-7005
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK#5111-P104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731545165Medicaid