Provider Demographics
NPI:1871244137
Name:BURNINGHAM, KALEB (LMFT, PHD)
Entity type:Individual
Prefix:DR
First Name:KALEB
Middle Name:
Last Name:BURNINGHAM
Suffix:
Gender:M
Credentials:LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15093 S HALTER WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1885
Mailing Address - Country:US
Mailing Address - Phone:801-995-8313
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY ROAD B W STE 204
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4053
Practice Address - Country:US
Practice Address - Phone:801-995-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001960-01106H00000X
MN3959106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist