Healthcare Provider Details

I. General information

NPI: 1346354875
Provider Name (Legal Business Name): FAMILY DEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8817 REDWOOD RD STE A
WEST JORDAN UT
84088-9266
US

IV. Provider business mailing address

8817 REDWOOD RD STE A
WEST JORDAN UT
84088-9266
US

V. Phone/Fax

Practice location:
  • Phone: 801-748-2270
  • Fax: 801-748-2271
Mailing address:
  • Phone: 801-748-2270
  • Fax: 801-748-2271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number108286-2501
License Number StateUT

VIII. Authorized Official

Name: MR. TERRY LEE BURNHAM
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 801-748-2270