Provider Demographics
NPI:1770761850
Name:SNOW, JUDITH ELLEN (MA)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ELLEN
Last Name:SNOW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Mailing Address - Street 2:SUITE 146
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5938
Mailing Address - Country:US
Mailing Address - Phone:616-954-9850
Mailing Address - Fax:616-954-9852
Practice Address - Street 1:3501 LAKE EASTBROOK BLVD SE
Practice Address - Street 2:SUITE 146
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5938
Practice Address - Country:US
Practice Address - Phone:616-954-9850
Practice Address - Fax:616-954-9852
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009661103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral