Provider Demographics
NPI:1043362197
Name:BURT, CHARLES ERNEST (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ERNEST
Last Name:BURT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:22563 FOREST MANOR DR
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-6900
Mailing Address - Country:US
Mailing Address - Phone:703-899-3290
Mailing Address - Fax:703-723-9404
Practice Address - Street 1:1800 MICHAEL FARADAY DR STE 206
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5312
Practice Address - Country:US
Practice Address - Phone:703-899-3290
Practice Address - Fax:703-723-9404
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA031200OtherVALUE OPTIONS PROVIDER ID
VA107617OtherANTHEM BXBS RESTON ADDR
54-1848078OtherFEDERAL EMPLOYER ID #
VA762716Medicare PIN