Provider Demographics
NPI:1093815201
Name:SNOW, BETHANY (OT)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:
Last Name:SNOW
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 DOBIE RD
Mailing Address - Street 2:STE 270
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6909
Mailing Address - Country:US
Mailing Address - Phone:517-980-0823
Mailing Address - Fax:
Practice Address - Street 1:1780 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-4998
Practice Address - Country:US
Practice Address - Phone:517-980-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005076225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30658OtherBCBSM
MI64-00940OtherPHP
MI64-00940OtherPHP