Provider Demographics
NPI:1881200806
Name:SCHMIDT, KATHELEEN (MED AND EDS)
Entity Type:Individual
Prefix:MRS
First Name:KATHELEEN
Middle Name:
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:MED AND EDS
Other - Prefix:
Other - First Name:KATHELEEN
Other - Middle Name:
Other - Last Name:HARTENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2411 PATHWAYS XING
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5885
Mailing Address - Country:US
Mailing Address - Phone:618-355-4700
Mailing Address - Fax:
Practice Address - Street 1:2411 PATHWAYS XING
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5885
Practice Address - Country:US
Practice Address - Phone:618-355-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2376264103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool