Provider Demographics
NPI:1861231649
Name:SNYDER, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SNYDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOUTWELLS LANDING
Mailing Address - Street 2:13575 58TH STREET NORTH
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-430-7222
Mailing Address - Fax:
Practice Address - Street 1:13575 58TH ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6620
Practice Address - Country:US
Practice Address - Phone:651-430-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201640224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty