Healthcare Provider Details

I. General information

NPI: 1659537751
Provider Name (Legal Business Name): SHANNON MARIE SNYDER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 W LAKE ST SUITE 210
MINNEAPOLIS MN
55416-4527
US

IV. Provider business mailing address

3100 W LAKE ST SUITE 210
MINNEAPOLIS MN
55416-4527
US

V. Phone/Fax

Practice location:
  • Phone: 612-925-6033
  • Fax: 612-925-8496
Mailing address:
  • Phone: 612-925-6033
  • Fax: 612-925-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14970
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: