Provider Demographics
NPI:1699396879
Name:SNOW, DOMINIC MCRAE
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:MCRAE
Last Name:SNOW
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 1:1014 N BRAGG BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-3316
Mailing Address - Country:US
Mailing Address - Phone:910-690-2822
Mailing Address - Fax:
Practice Address - Street 1:1014 N BRAGG BLVD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3316
Practice Address - Country:US
Practice Address - Phone:910-690-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician