Provider Demographics
NPI:1205892114
Name:SANFORD, MARY EVE (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EVE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 E 3900 S
Mailing Address - Street 2:#B150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1216
Mailing Address - Country:US
Mailing Address - Phone:801-262-3441
Mailing Address - Fax:801-269-9005
Practice Address - Street 1:1151 E 3900 S
Practice Address - Street 2:#B150
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1216
Practice Address - Country:US
Practice Address - Phone:801-262-3441
Practice Address - Fax:801-269-9005
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1116982501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1760Medicaid
UTD1760Medicaid