Provider Demographics
NPI:1598348393
Name:DIVER, SANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DIVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15831 BARONS WAY DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7111
Mailing Address - Country:US
Mailing Address - Phone:131-476-6223
Mailing Address - Fax:
Practice Address - Street 1:301 SOVEREIGN CT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4441
Practice Address - Country:US
Practice Address - Phone:636-200-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026374101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health