Healthcare Provider Details

I. General information

NPI: 1578643243
Provider Name (Legal Business Name): KIM B BURGESS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-1779
  • Fax:
Mailing address:
  • Phone: 703-784-1779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number03725
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number03725
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number03725
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: