Healthcare Provider Details

I. General information

NPI: 1245414713
Provider Name (Legal Business Name): RANDY JAMES SNYDER MSW/LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 COMO AVE SUITE 201
SAINT PAUL MN
55108-1737
US

IV. Provider business mailing address

2265 COMO AVE SUITE 201
SAINT PAUL MN
55108-1737
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-8985
  • Fax: 651-646-3959
Mailing address:
  • Phone: 651-646-8985
  • Fax: 651-646-3959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16442
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: