Healthcare Provider Details

I. General information

NPI: 1033588181
Provider Name (Legal Business Name): CLAY SNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17533 W ROCK LEDGE RD
GOODYEAR AZ
85338-5723
US

IV. Provider business mailing address

17533 W ROCK LEDGE RD
GOODYEAR AZ
85338-5723
US

V. Phone/Fax

Practice location:
  • Phone: 623-850-9242
  • Fax:
Mailing address:
  • Phone: 623-850-9242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number6527993
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: