Provider Demographics
NPI:1346248812
Name:BURKE, WILLIAM T (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
Last Name:BURKE
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 1:5001 W VILLAGE GREEN DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4801
Mailing Address - Country:US
Mailing Address - Phone:804-744-9652
Mailing Address - Fax:804-744-1265
Practice Address - Street 1:5001 W VILLAGE GREEN DR
Practice Address - Street 2:SUITE 211
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4801
Practice Address - Country:US
Practice Address - Phone:804-744-9652
Practice Address - Fax:804-744-1265
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7709714Medicaid
VA7709714Medicaid