Provider Demographics
NPI:1033326459
Name:BURCH, CLYDE R (PHD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:R
Last Name:BURCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5015
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-0915
Mailing Address - Country:US
Mailing Address - Phone:925-837-5575
Mailing Address - Fax:
Practice Address - Street 1:931 HARTZ WAY
Practice Address - Street 2:SUITE 130
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-3465
Practice Address - Country:US
Practice Address - Phone:925-837-5575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13655103G00000X, 103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TP2701X, 103TR0400X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Not Answered103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPP000Medicare UPIN