Healthcare Provider Details

I. General information

NPI: 1578181053
Provider Name (Legal Business Name): MATTHEW MARTIN SNISCAK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S 4TH ST STE 471
PHILADELPHIA PA
19147-1582
US

IV. Provider business mailing address

525 S 4TH ST STE 471
PHILADELPHIA PA
19147-1582
US

V. Phone/Fax

Practice location:
  • Phone: 267-861-3685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC012507
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: