Provider Demographics
NPI:1114957396
Name:BURGOYNE, RAYMOND H (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:H
Last Name:BURGOYNE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 N 825 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-1952
Mailing Address - Country:US
Mailing Address - Phone:801-756-4619
Mailing Address - Fax:
Practice Address - Street 1:433 S 500 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2527
Practice Address - Country:US
Practice Address - Phone:801-216-8000
Practice Address - Fax:801-216-8001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT100789-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical