Healthcare Provider Details

I. General information

NPI: 1306301809
Provider Name (Legal Business Name): BREANNA SNYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 N KIRKWOOD RD # 1
KIRKWOOD MO
63122-3911
US

IV. Provider business mailing address

5220 6TH STREET FRONTAGE RD E STE 1700
SPRINGFIELD IL
62703-5771
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-8332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-34342
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: