Provider Demographics
NPI:1255095576
Name:BURGOYNE, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:BURGOYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:DANIEL
Other - Last Name:BURGOYNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:625 W 200 N
Mailing Address - Street 2:APT A306
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321
Mailing Address - Country:US
Mailing Address - Phone:801-695-8177
Mailing Address - Fax:
Practice Address - Street 1:625 W 200 N
Practice Address - Street 2:APT A306
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:801-695-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician