Provider Demographics
NPI:1558795237
Name:BURNHAM, GREG (LMFT)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:BURNHAM
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 1:1739 S HIGHWAY 89A
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-3957
Mailing Address - Country:US
Mailing Address - Phone:801-380-4386
Mailing Address - Fax:
Practice Address - Street 1:1739 S HIGHWAY 89A
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3957
Practice Address - Country:US
Practice Address - Phone:801-380-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4910479-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist