Healthcare Provider Details

I. General information

NPI: 1194035642
Provider Name (Legal Business Name): SUSIE SNYDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 SE HAWTHORNE BLVD
PORTLAND OR
97215-3370
US

IV. Provider business mailing address

5616 SE HAWTHORNE BLVD.
PORTLAND OR
97215-3370
US

V. Phone/Fax

Practice location:
  • Phone: 503-233-2442
  • Fax:
Mailing address:
  • Phone: 503-233-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1020
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: