Basic Information
| Provider Information | |||||||||
| NPI: | 1437539194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 W. CHOCTAW | ||||||||
| Address2: | |||||||||
| City: | CHICKASAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052220622 | ||||||||
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| Practice Location | |||||||||
| Address1: | 807 SW F AVE | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735014506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805957000 | ||||||||
| FaxNumber: | 5805957005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2015 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | #5111-P | OK | Y | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | #5111-P | OK | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 731545165 | 05 | OK | MEDICAID |