Provider Demographics
NPI:1386196830
Name:BURNHAM, TRACY (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 E PAGES LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 E PAGES LN
Practice Address - Street 2:SUITE A
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2216
Practice Address - Country:US
Practice Address - Phone:801-294-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10129124-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical