Provider Demographics
NPI:1710430830
Name:SCHROEDER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:1286 CALLEN ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3002
Mailing Address - Country:US
Mailing Address - Phone:707-447-8982
Mailing Address - Fax:707-447-3205
Practice Address - Street 1:1735 ENTERPRISE DR STE 105A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6822
Practice Address - Country:US
Practice Address - Phone:707-425-1799
Practice Address - Fax:707-425-1081
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health