Provider Demographics
NPI:1922106947
Name:SNYDER, THERESA LEE (COTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LEE
Last Name:SNYDER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:LEE
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:172 PIERCE RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18407-3802
Mailing Address - Country:US
Mailing Address - Phone:570-222-2139
Mailing Address - Fax:570-307-1771
Practice Address - Street 1:334 MAIN ST
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1620
Practice Address - Country:US
Practice Address - Phone:570-307-1769
Practice Address - Fax:570-307-1771
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP001823L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist