Healthcare Provider Details

I. General information

NPI: 1093334583
Provider Name (Legal Business Name): JEFFREY THOMAS SNYDER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 RADOM AVE
SAINT LOUIS MO
63116-2251
US

IV. Provider business mailing address

5000 CEDAR PLAZA PKWY
SAINT LOUIS MO
63128-3841
US

V. Phone/Fax

Practice location:
  • Phone: 314-481-0786
  • Fax:
Mailing address:
  • Phone: 314-481-0786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: