Provider Demographics
NPI:1356303218
Name:BURNHAM, TERRY LEE (PHD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8817 REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9266
Mailing Address - Country:US
Mailing Address - Phone:801-748-2270
Mailing Address - Fax:801-748-2271
Practice Address - Street 1:8817 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9271
Practice Address - Country:US
Practice Address - Phone:801-748-2270
Practice Address - Fax:801-748-2271
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT108286-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical