Provider Demographics
NPI:1912124850
Name:BURLINGAME, GARY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:BURLINGAME
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 1:1190 NORTH 900 EAST
Mailing Address - Street 2:239 TLRB: BYU COMPREHENSIVE CLINIC
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602
Mailing Address - Country:US
Mailing Address - Phone:801-422-7557
Mailing Address - Fax:
Practice Address - Street 1:11085 YARROW CIR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-9598
Practice Address - Country:US
Practice Address - Phone:801-422-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112948-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical