Provider Demographics
NPI:1760952535
Name:SCHREINER-TATA, PHYLLIS E (LCAC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:E
Last Name:SCHREINER-TATA
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 KNIGHTWAY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5033
Mailing Address - Country:US
Mailing Address - Phone:260-433-9899
Mailing Address - Fax:
Practice Address - Street 1:6201 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1517
Practice Address - Country:US
Practice Address - Phone:260-494-1142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001594A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)