Provider Demographics
NPI:1598027674
Name:BURBANK, TRICIA (PT)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:BURBANK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E FOREMASTER DR
Mailing Address - Street 2:STE 110
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4492
Mailing Address - Country:US
Mailing Address - Phone:435-525-1877
Mailing Address - Fax:435-215-7665
Practice Address - Street 1:780 N 2860 E STE 202
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8707
Practice Address - Country:US
Practice Address - Phone:435-525-1877
Practice Address - Fax:435-215-7665
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6210745-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist