Healthcare Provider Details

I. General information

NPI: 1770761850
Provider Name (Legal Business Name): JUDITH ELLEN SNOW M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE SUITE 146
GRAND RAPIDS MI
49546-5938
US

IV. Provider business mailing address

3501 LAKE EASTBROOK BLVD SE SUITE 146
GRAND RAPIDS MI
49546-5938
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-9850
  • Fax: 616-954-9852
Mailing address:
  • Phone: 616-954-9850
  • Fax: 616-954-9852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301009661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: