Provider Demographics
NPI:1972713626
Name:BURSON, PHYLLIS JEAN (PHD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:JEAN
Last Name:BURSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:JEAN
Other - Last Name:BIESEMEIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:7501 ELMORE LANE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817
Mailing Address - Country:US
Mailing Address - Phone:301-229-9224
Mailing Address - Fax:
Practice Address - Street 1:7501 ELMORE LANE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817
Practice Address - Country:US
Practice Address - Phone:301-229-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1075103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216241500Medicaid
A910MEMBER0001OtherCARE FIRST BCBS NCA
MD216241500Medicaid