Healthcare Provider Details

I. General information

NPI: 1144625302
Provider Name (Legal Business Name): TODD SNYDER LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 POND ST
WATERTOWN MA
02472-2564
US

IV. Provider business mailing address

PO BOX 79062
WAVERLEY MA
02479-0062
US

V. Phone/Fax

Practice location:
  • Phone: 617-947-9968
  • Fax:
Mailing address:
  • Phone: 617-947-9968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5717
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: