Provider Demographics
NPI:1104673201
Name:DIMERY, SANDRA DENISE (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:DENISE
Last Name:DIMERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4185 CHICAGO AVE P.O. BOX 56243
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517
Mailing Address - Country:US
Mailing Address - Phone:559-301-1258
Mailing Address - Fax:
Practice Address - Street 1:19191 ONTARIO AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-9689
Practice Address - Country:US
Practice Address - Phone:559-301-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical