MEDICARE: MRS. ILENE FAY SCHALLER MSW LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	002698	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	35978015	OTHER	MO	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1568457885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ILENE FAY SCHALLER MSW LCSW

Provider Business Mailing Address
First Line	:	4208 KENSINGTON DR
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-4550
Country	:	US
Telephone Number	:	816-233-9998
Fax Number	:	816-279-9666

Provider Business Practice Location Address
First Line	:	4208 KENSINGTON DR
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-4550
Country	:	US
Telephone Number	:	816-233-9998
Fax Number	:	816-279-9666

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	07/08/2007

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