Basic Information
| Provider Information | |||||||||
| NPI: | 1891758736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHRADER | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MALPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRAZIER | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MALPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16942 HOLIDAY CIR | ||||||||
| Address2: | |||||||||
| City: | BOONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652333529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608822333 | ||||||||
| FaxNumber: | 6608822333 | ||||||||
| Practice Location | |||||||||
| Address1: | 15899 LOGANS LAKE RD | ||||||||
| Address2: | |||||||||
| City: | BOONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652332866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608822333 | ||||||||
| FaxNumber: | 6608822333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2005038682 | MO | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1538204904 | 01 | MO | BOONVILLE LOCATION NPI | OTHER | 1649269622 | 01 | MO | BILLING NPI | OTHER |