Provider Demographics
NPI:1205581832
Name:FLORES, DIEGO GONZALO (PHD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:GONZALO
Last Name:FLORES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 5600 S STE 304
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8174
Mailing Address - Country:US
Mailing Address - Phone:801-272-3420
Mailing Address - Fax:
Practice Address - Street 1:111 E 5600 S STE 304
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8174
Practice Address - Country:US
Practice Address - Phone:801-272-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12310540-2504103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist