=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154300663
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH R SCHNEIDER PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2006
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1820 23RD AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-513-4268
-----------------------------------------------------
Fax | 601-282-5851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1820 23RD AVE
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-513-4268
-----------------------------------------------------
Fax | 601-282-5851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 29421
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------