MEDICARE: MRS. TONYA KAY SCHRADER MS CCC SLP

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	235Z00000X	Speech-Language Pathologist	7578	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46-01122	OTHER	MN	MEDICA
2	C08611048584	OTHER	MN	PREFERRED ONE
3	030N8SC	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1811091176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TONYA KAY SCHRADER MS CCC SLP

Provider Business Mailing Address
First Line	:	204 LEWIS AVE S
Second Line	:	SUITE 104
City	:	WATERTOWN
State	:	MN
Zip	:	55388-4500
Country	:	US
Telephone Number	:	952-955-3323
Fax Number	:	952-255-8075

Provider Business Practice Location Address
First Line	:	204 LEWIS AVE S
Second Line	:	SUITE 104
City	:	WATERTOWN
State	:	MN
Zip	:	55388-4500
Country	:	US
Telephone Number	:	952-955-3323
Fax Number	:	952-255-8075

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

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	07/17/2007

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