Provider Demographics
NPI:1194277541
Name:SNOW, CARRIE (MS ED, QIDP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:SNOW
Suffix:
Gender:F
Credentials:MS ED, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W LAMM RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9630
Mailing Address - Country:US
Mailing Address - Phone:815-233-6162
Mailing Address - Fax:815-233-6167
Practice Address - Street 1:701 W LAMM RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9630
Practice Address - Country:US
Practice Address - Phone:815-233-6162
Practice Address - Fax:815-233-6167
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371372148Medicaid