Healthcare Provider Details

I. General information

NPI: 1114250768
Provider Name (Legal Business Name): TRACY LYNN SNYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 CAPITOL ST NE STE A
SALEM OR
97301-1201
US

IV. Provider business mailing address

1735 SNOWBIRD DR NW
SALEM OR
97304-2051
US

V. Phone/Fax

Practice location:
  • Phone: 503-507-9334
  • Fax:
Mailing address:
  • Phone: 503-507-9334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16104
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: