Healthcare Provider Details

I. General information

NPI: 1811335870
Provider Name (Legal Business Name): TYSON SNYDER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 E 20TH ST STE 204
FARMINGTON NM
87402-4411
US

IV. Provider business mailing address

4340 CARDON DR
FARMINGTON NM
87401-9282
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-0241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0154681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: