Provider Demographics
NPI:1790735025
Name:BURCH-BROWN, MARY ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:BURCH-BROWN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:708 MOBJACK PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1957
Mailing Address - Country:US
Mailing Address - Phone:757-873-1958
Mailing Address - Fax:757-873-2143
Practice Address - Street 1:708 MOBJACK PL
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1957
Practice Address - Country:US
Practice Address - Phone:757-873-1958
Practice Address - Fax:757-873-2143
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA68000250Medicaid
VA007725604Medicare ID - Type UnspecifiedPSYCHOLOGIST