Provider Demographics
NPI:1518007640
Name:CHARLES E. BURT, PH.D. AND ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:CHARLES E. BURT, PH.D. AND ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-899-3290
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA031200OtherVALUE OPTIONS PROVIDER #
VA107617OtherANTHEM BXBS
VA107617OtherANTHEM BXBS