Provider Demographics
NPI:1528020526
Name:BURD, MARC ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ALLEN
Last Name:BURD
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 1:50 EAST FIRST ST.
Mailing Address - Street 2:SUITE #17
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9334
Mailing Address - Country:US
Mailing Address - Phone:917-744-5006
Mailing Address - Fax:718-848-3166
Practice Address - Street 1:130-22 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:917-744-5006
Practice Address - Fax:718-868-3166
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014832103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02637209Medicaid