Provider Demographics
NPI:1942085857
Name:SNOW, ELLIOT ANNA (LMT, CLT)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:ANNA
Last Name:SNOW
Suffix:
Gender:F
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7228 S OKETO AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1148
Mailing Address - Country:US
Mailing Address - Phone:765-714-5257
Mailing Address - Fax:
Practice Address - Street 1:814 HILLGROVE AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1439
Practice Address - Country:US
Practice Address - Phone:708-637-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227022229225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist