Basic Information
| Provider Information | |||||||||
| NPI: | 1962919324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHROEDER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 NW TOWER DR | ||||||||
| Address2: | |||||||||
| City: | PLATTE WOODS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641514463 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5420 W 151RST ST. | ||||||||
| Address2: | |||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132195696 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2018 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 2019014046 | MO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | BACB348220 | 01 | MO | TRICARE | OTHER |