Provider Demographics
NPI:1477533412
Name:ROSE, BARRY
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:ROSE
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 1:3944 S 400 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3944 S 400 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1600
Practice Address - Country:US
Practice Address - Phone:801-261-1442
Practice Address - Fax:801-261-9569
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9713639635011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS74153OtherICAR
UT107032376101OtherINTERMOUNTAIN HEALTH CARE
UT942938348R02OtherU003-EDUCATORS MUTUAL
UT341613OtherU002-DESERET MUTUAL
UTS74153Medicare UPIN