Provider Demographics
NPI:1154811206
Name:BURCHBY, KEVIN DALE (PSYD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
Last Name:BURCHBY
Suffix:
Gender:M
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:PO BOX 910646
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0646
Mailing Address - Country:US
Mailing Address - Phone:858-692-3685
Mailing Address - Fax:
Practice Address - Street 1:8950 VILLA LA JOLLA DR STE B204
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1705
Practice Address - Country:US
Practice Address - Phone:858-215-2675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA31247103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor