Provider Demographics
NPI:1881240513
Name:SNYDER, BROOKE NICOLE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
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 1:411 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3932
Mailing Address - Country:US
Mailing Address - Phone:740-354-6685
Mailing Address - Fax:740-876-4005
Practice Address - Street 1:411 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3932
Practice Address - Country:US
Practice Address - Phone:740-354-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
QMHS101YM0800X
CMS171M00000X
OHCDCA.175467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0382207Medicaid
OH0365128Medicaid