=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093334583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY THOMAS SNYDER LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2020
-----------------------------------------------------
Last Update Date | 04/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6201 RADOM AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63116-2251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-481-0786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 CEDAR PLAZA PKWY
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-481-0786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 002667
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------