Provider Demographics
NPI:1023162682
Name:SNOW, MARK E (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:SNOW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:E
Other - Last Name:SNOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:311 N. ALLUMBAUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9208
Mailing Address - Country:US
Mailing Address - Phone:208-375-6402
Mailing Address - Fax:208-323-1850
Practice Address - Street 1:311 N. ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9208
Practice Address - Country:US
Practice Address - Phone:208-375-6402
Practice Address - Fax:208-323-1850
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-61103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015907OtherREGENCE BLUE SHIELD
IDN0617OtherBLUE CROSS
ID16806441Medicare PIN