Healthcare Provider Details

I. General information

NPI: 1760540967
Provider Name (Legal Business Name): RENEE BURDETT, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13649 OFFICE PLACE SUITE 102
WOODBRIDGE VA
22192
US

IV. Provider business mailing address

13649 OFFICE PLACE SUITE 102
WOODBRIDGE VA
22192
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-5738
  • Fax: 703-670-8213
Mailing address:
  • Phone: 703-670-5738
  • Fax: 703-670-8213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: V RENEE BURDETT
Title or Position: MEDICAL DIRECTOR CEO
Credential: MD
Phone: 703-670-5738