Provider Demographics
NPI:1558495481
Name:SCHROEDER, ILENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 SEMINOLE AVE NE
Mailing Address - Street 2:STE 107
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-3411
Mailing Address - Country:US
Mailing Address - Phone:404-873-6840
Mailing Address - Fax:404-881-8410
Practice Address - Street 1:675 SEMINOLE AVE NE
Practice Address - Street 2:STE 107
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-3411
Practice Address - Country:US
Practice Address - Phone:404-873-6840
Practice Address - Fax:404-881-8410
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001104103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCMVMedicare ID - Type Unspecified