Healthcare Provider Details

I. General information

NPI: 1558907956
Provider Name (Legal Business Name): CHANCEY ALLEN SNYDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 42ND ST S
FARGO ND
58103-2119
US

IV. Provider business mailing address

900 42ND ST S
FARGO ND
58103-2119
US

V. Phone/Fax

Practice location:
  • Phone: 701-212-9275
  • Fax:
Mailing address:
  • Phone: 701-212-9275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier502363652
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: