Provider Demographics
NPI:1104902436
Name:BURNSIDE, MARY ARDIS (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ARDIS
Last Name:BURNSIDE
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 1:6750 WEST LOOP SOUTH
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401
Mailing Address - Country:US
Mailing Address - Phone:713-661-9767
Mailing Address - Fax:713-661-5803
Practice Address - Street 1:6750 WEST LOOP SOUTH
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401
Practice Address - Country:US
Practice Address - Phone:713-661-9767
Practice Address - Fax:713-661-5803
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22199103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R58964Medicare UPIN
TX00SD98Medicare ID - Type Unspecified