Provider Demographics
NPI:1023220589
Name:SANFORD, DIANE G (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:G
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 N NEW BALLAS RD
Mailing Address - Street 2:SUITE 195
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6814
Mailing Address - Country:US
Mailing Address - Phone:314-991-5666
Mailing Address - Fax:314-991-0666
Practice Address - Street 1:425 N NEW BALLAS RD
Practice Address - Street 2:SUITE 195
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6814
Practice Address - Country:US
Practice Address - Phone:314-991-5666
Practice Address - Fax:314-991-0666
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01223103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000070186Medicare ID - Type UnspecifiedPSYCHOLOGIST