Basic Information
Provider Information | |||||||||
NPI: | 1033126891 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SNYDER | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3330 CLAYSTONE ST SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495465765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6169497460 | ||||||||
FaxNumber: | 6169493018 | ||||||||
Practice Location | |||||||||
Address1: | 3330 CLAYSTONE ST SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495465765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6169497460 | ||||||||
FaxNumber: | 6169493018 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301009158 | MI | X |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TA0400X | 1-01610 | MI | X |   | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 11289266 | 01 | MI | CAQH | OTHER | 68OD146520 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | P106527 | 01 | MI | BLUE CARE NETWORK | OTHER |