MEDICARE: DR. ILENE SCHROEDER PH.D.

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	PSY001104	GA

General Provider Information

NPI Number	:	1558495481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ILENE SCHROEDER PH.D.

Provider Business Mailing Address
First Line	:	675 SEMINOLE AVE NE
Second Line	:	STE 107
City	:	ATLANTA
State	:	GA
Zip	:	30307-3411
Country	:	US
Telephone Number	:	404-873-6840
Fax Number	:	404-881-8410

Provider Business Practice Location Address
First Line	:	675 SEMINOLE AVE NE
Second Line	:	STE 107
City	:	ATLANTA
State	:	GA
Zip	:	30307-3411
Country	:	US
Telephone Number	:	404-873-6840
Fax Number	:	404-881-8410

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	09/07/2011

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