Provider Demographics
NPI:1588142608
Name:SNOW, CARLY BROOKE (MA, AMFT, 1000-ERYT)
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:BROOKE
Last Name:SNOW
Suffix:
Gender:F
Credentials:MA, AMFT, 1000-ERYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 S HOLLADAY BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7054
Mailing Address - Country:US
Mailing Address - Phone:609-313-1411
Mailing Address - Fax:
Practice Address - Street 1:4624 S HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7054
Practice Address - Country:US
Practice Address - Phone:801-558-5950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10836864-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist