Provider Demographics
NPI:1487934782
Name:SNELL, MAX CLEATIS
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:CLEATIS
Last Name:SNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7940 BODEGA AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3566
Mailing Address - Country:US
Mailing Address - Phone:530-401-5075
Mailing Address - Fax:
Practice Address - Street 1:7940 BODEGA AVE APT 13
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3566
Practice Address - Country:US
Practice Address - Phone:530-401-5075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness