Healthcare Provider Details

I. General information

NPI: 1396886404
Provider Name (Legal Business Name): ELISSA M SCHROEDER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALICE MAE SCHROEDER PH.D.

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 BRIARCLIFF RD
WINSTON SALEM NC
27106-3077
US

IV. Provider business mailing address

2910 BRIARCLIFF RD
WINSTON SALEM NC
27106-3077
US

V. Phone/Fax

Practice location:
  • Phone: 336-722-0040
  • Fax: 336-773-0332
Mailing address:
  • Phone: 336-722-0040
  • Fax: 336-773-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number749
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: