Healthcare Provider Details

I. General information

NPI: 1821474016
Provider Name (Legal Business Name): SANDRA CHACON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 N PUGSLEY ST
SALT LAKE CITY UT
84103-1329
US

IV. Provider business mailing address

1595 N MANDALAY RD
SALT LAKE CITY UT
84116-4130
US

V. Phone/Fax

Practice location:
  • Phone: 385-261-2171
  • Fax: 385-261-2827
Mailing address:
  • Phone: 801-991-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10366619-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: