MEDICARE: LISA JEAN BRUNE MSSW LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW # 30998	TX
2	1041C0700X	Clinical Social Worker	LCSW BACS #10755	LA

General Provider Information

NPI Number	:	1205066479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JEAN BRUNE MSSW LCSW

Provider Business Mailing Address
First Line	:	4016 HOLLY HILL RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2533
Country	:	US
Telephone Number	:	337-284-9779
Fax Number	:	337-282-7967

Provider Business Practice Location Address
First Line	:	4016 HOLLY HILL RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-2533
Country	:	US
Telephone Number	:	337-284-9779
Fax Number	:	337-282-7967

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2009
Last Update Date	:	05/08/2023

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