Healthcare Provider Details

I. General information

NPI: 1356168173
Provider Name (Legal Business Name): HARRISON LORENZO BURTON SR. RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 EUCLID AVE STE 102
SAN DIEGO CA
92114-3611
US

IV. Provider business mailing address

286 EUCLID AVE STE 102
SAN DIEGO CA
92114-3611
US

V. Phone/Fax

Practice location:
  • Phone: 619-859-6270
  • Fax: 619-527-8536
Mailing address:
  • Phone: 619-859-6270
  • Fax: 619-527-8536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1546350124
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: