Provider Demographics
NPI:1205308475
Name:SNIDER, REBECCA ANN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:SNIDER
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 1:9111 113TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3643
Mailing Address - Country:US
Mailing Address - Phone:208-573-6048
Mailing Address - Fax:
Practice Address - Street 1:3901 S FIFE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7309
Practice Address - Country:US
Practice Address - Phone:208-573-6048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60902224175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60902224Medicaid