Provider Demographics
NPI:1285189514
Name:BURGESS, DANIEL ALLEN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ALLEN
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84603-0902
Mailing Address - Country:US
Mailing Address - Phone:408-431-4443
Mailing Address - Fax:
Practice Address - Street 1:4665 MILE HIGH DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6311
Practice Address - Country:US
Practice Address - Phone:408-431-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105383106H00000X
UT11952129-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist