Provider Demographics
NPI:1326561184
Name:BUR, MARK (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BUR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:ORELAND
Mailing Address - State:PA
Mailing Address - Zip Code:19075-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1613
Practice Address - Country:US
Practice Address - Phone:215-206-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018305103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical