Healthcare Provider Details

I. General information

NPI: 1902154537
Provider Name (Legal Business Name): DAVID SNOW LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 NORTHERN AVE
ROCKFORD IL
61107-5309
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-338-8003
  • Fax: 815-332-6090
Mailing address:
  • Phone: 815-387-5600
  • Fax: 815-391-5041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178-006508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: