Provider Demographics
NPI:1992828628
Name:BURKHART, MARY ALYCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALYCE
Last Name:BURKHART
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347-1450
Mailing Address - Country:US
Mailing Address - Phone:207-621-1776
Mailing Address - Fax:207-621-0692
Practice Address - Street 1:93 SECOND ST
Practice Address - Street 2:
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347-1450
Practice Address - Country:US
Practice Address - Phone:207-621-1776
Practice Address - Fax:207-621-0692
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS762103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM4103Medicare ID - Type Unspecified