Provider Demographics
NPI:1285395038
Name:SNOW, ROBERT DYLAN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DYLAN
Last Name:SNOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-5112
Mailing Address - Country:US
Mailing Address - Phone:801-355-2846
Mailing Address - Fax:
Practice Address - Street 1:1875 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-5112
Practice Address - Country:US
Practice Address - Phone:801-355-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTCPSSCT-01958175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist