Provider Demographics
NPI:1104142496
Name:BURGH, ILANA ILKOVITCH (PSYD)
Entity type:Individual
Prefix:DR
First Name:ILANA
Middle Name:ILKOVITCH
Last Name:BURGH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 INTERNATIONAL DR
Mailing Address - Street 2:327
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1645 INTERNATIONAL DR
Practice Address - Street 2:327
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4816
Practice Address - Country:US
Practice Address - Phone:240-354-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004048103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical