Provider Demographics
NPI:1396886404
Name:SCHROEDER, ELISSA M (PHD)
Entity type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:M
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MAE
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2910 BRIARCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3077
Mailing Address - Country:US
Mailing Address - Phone:336-722-0040
Mailing Address - Fax:336-773-0332
Practice Address - Street 1:2910 BRIARCLIFF RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3077
Practice Address - Country:US
Practice Address - Phone:336-722-0040
Practice Address - Fax:336-773-0332
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2811875AMedicare ID - Type Unspecified