Provider Demographics
NPI:1609408145
Name:SHUPRUDKO, DIANA GALINA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:GALINA
Last Name:SHUPRUDKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3748 OAKLAND BAY DR
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-5936
Mailing Address - Country:US
Mailing Address - Phone:916-450-0360
Mailing Address - Fax:
Practice Address - Street 1:1901 ROYAL OAKS DR STE 201
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4235
Practice Address - Country:US
Practice Address - Phone:916-923-1789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician