Provider Demographics
NPI:1306109988
Name:VANWAGONER, DIANE (LPC)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:VANWAGONER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2297 HILLRISE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-8025
Mailing Address - Country:US
Mailing Address - Phone:801-541-1308
Mailing Address - Fax:
Practice Address - Street 1:135 N 900 E
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3024
Practice Address - Country:US
Practice Address - Phone:801-541-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
UT332660-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional