Provider Demographics
NPI:1346219243
Name:BURGIN, SALLY SUE (MSW/LCSW)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:SUE
Last Name:BURGIN
Suffix:
Gender:F
Credentials:MSW/LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E SOUTH TEMPLE
Mailing Address - Street 2:#A 30
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1013
Mailing Address - Country:US
Mailing Address - Phone:801-537-5008
Mailing Address - Fax:801-355-5132
Practice Address - Street 1:508 E SOUTH TEMPLE
Practice Address - Street 2:#A 30
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1013
Practice Address - Country:US
Practice Address - Phone:801-537-5008
Practice Address - Fax:801-355-5132
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133051-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP43980Medicare UPIN