Basic Information
| Provider Information | |||||||||
| NPI: | 1679752422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURT | ||||||||
| FirstName: | LEZLI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURT | ||||||||
| OtherFirstName: | LEZLI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5965 S 900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841211720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012637100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7309 S 180 W | ||||||||
| Address2: | |||||||||
| City: | MIDVALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840471020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015656800 | ||||||||
| FaxNumber: | 8015699718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 66266763502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.