Healthcare Provider Details

I. General information

NPI: 1841576758
Provider Name (Legal Business Name): SANDRA B. DIEDRICH LPC, LPC-MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 3RD ST
BROOKINGS SD
57006-2605
US

IV. Provider business mailing address

2120 3RD ST
BROOKINGS SD
57006-2605
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-3871
  • Fax: 605-692-0961
Mailing address:
  • Phone: 605-692-3871
  • Fax: 605-692-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC7068
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-MH2215
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: