Provider Demographics
NPI:1578864096
Name:THREEDY, DIANE M
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:THREEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:THREEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1371 MURPHYS LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2931
Mailing Address - Country:US
Mailing Address - Phone:801-355-1528
Mailing Address - Fax:801-364-4085
Practice Address - Street 1:660 S 200 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3835
Practice Address - Country:US
Practice Address - Phone:801-355-1528
Practice Address - Fax:801-364-4085
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT943008720101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT943008720Medicaid