MEDICARE: MS. SALLY SUE BURGIN MSW/LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	133051-3501	UT

General Provider Information

NPI Number	:	1346219243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY SUE BURGIN MSW/LCSW

Provider Business Mailing Address
First Line	:	508 E SOUTH TEMPLE
Second Line	:	#A 30
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1013
Country	:	US
Telephone Number	:	801-537-5008
Fax Number	:	801-355-5132

Provider Business Practice Location Address
First Line	:	508 E SOUTH TEMPLE
Second Line	:	#A 30
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1013
Country	:	US
Telephone Number	:	801-537-5008
Fax Number	:	801-355-5132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	07/09/2007

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