Basic Information
| Provider Information | |||||||||
| NPI: | 1306803085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN SNYDER | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SNYDER | ||||||||
| OtherFirstName: | LEEANNA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPARTMENT 272801 | ||||||||
| Address2: | PO BOX 67000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482672728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178416913 | ||||||||
| FaxNumber: | 5178416917 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884730 | ||||||||
| FaxNumber: | 5177884701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301010526 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.