Provider Demographics
NPI:1447382494
Name:BURGESS, VICTORIA D (PHD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:D
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:ERICA
Other - Middle Name:OLSON
Other - Last Name:VERMAAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:963 E 7400 S
Mailing Address - Street 2:#304
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5678
Mailing Address - Country:US
Mailing Address - Phone:801-359-9255
Mailing Address - Fax:
Practice Address - Street 1:963 E 7400 S
Practice Address - Street 2:#304
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-5678
Practice Address - Country:US
Practice Address - Phone:801-359-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT87-111805-2501103TC0700X
UT83-111805-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist