Basic Information
| Provider Information | |||||||||
| NPI: | 1558340406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHRADER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | PSYCHOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY DR | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608858131 | ||||||||
| FaxNumber: | 8163183001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 REMINGTON PLZ | ||||||||
| Address2: | |||||||||
| City: | RAYMORE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640838640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884031071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 01563 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 496809617 | 05 | MO | MEDICAID | 23988057 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER |