Provider Demographics
NPI:1558650689
Name:SANDOVAL, DIANE LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LOUISE
Other - Last Name:DRAPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:735 E 9000 S STE 100
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3089
Mailing Address - Country:US
Mailing Address - Phone:801-759-3727
Mailing Address - Fax:803-746-5713
Practice Address - Street 1:741 E 9000 S STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3086
Practice Address - Country:US
Practice Address - Phone:801-759-3727
Practice Address - Fax:803-746-5713
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT808949835061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor