Healthcare Provider Details

I. General information

NPI: 1497130124
Provider Name (Legal Business Name): LINDA DIANE BURHANS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 MAJOR AVE
RIVERTON WY
82501-2342
US

IV. Provider business mailing address

1110 MAJOR AVE
RIVERTON WY
82501-2342
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-6587
  • Fax: 307-856-2668
Mailing address:
  • Phone: 307-856-6587
  • Fax: 307-856-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1059
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-1059
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: