Healthcare Provider Details

I. General information

NPI: 1811262439
Provider Name (Legal Business Name): LAURA JOAN BURLINGAME-LEE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 W CHERRY LN STE 204
MERIDIAN ID
83642-8530
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3300
  • Fax: 208-302-3355
Mailing address:
  • Phone: 208-367-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-203095
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7163
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: