Provider Demographics
NPI:1982307310
Name:SNOW, TIARA
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:SNOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HUMMERT ST
Mailing Address - Street 2:P.O BOX 475
Mailing Address - City:BECKEMEYER
Mailing Address - State:IL
Mailing Address - Zip Code:62219-0461
Mailing Address - Country:US
Mailing Address - Phone:618-789-1988
Mailing Address - Fax:
Practice Address - Street 1:343 FOUNTAIN PKWY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-515-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-264926106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician