Provider Demographics
NPI:1174584957
Name:SCHUDERER, JOHN M (LISAC LPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SCHUDERER
Suffix:
Gender:M
Credentials:LISAC LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 DAMERON DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2411
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:928-776-8484
Practice Address - Street 1:642 DAMERON DR
Practice Address - Street 2:WEST YAVAPAI GUIDANCE CLINIC INC HILLSIDE CD
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2411
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-776-8484
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC11381101YA0400X
AZLPC10607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ739485Medicaid