Provider Demographics
NPI:1477511137
Name:BURTON, MARY KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:BURTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1970 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6404
Mailing Address - Country:US
Mailing Address - Phone:540-982-2463
Mailing Address - Fax:540-224-1957
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:540-224-1957
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001971103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical