Provider Demographics
NPI:1528629391
Name:SNOW, MOLLY JO
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
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 1:1251 MAPLE LEAF CT
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-3465
Mailing Address - Country:US
Mailing Address - Phone:937-335-3701
Mailing Address - Fax:937-335-7291
Practice Address - Street 1:1100 WAYNE ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3048
Practice Address - Country:US
Practice Address - Phone:937-335-3701
Practice Address - Fax:937-335-7291
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1962969469Medicaid