Healthcare Provider Details

I. General information

NPI: 1750472841
Provider Name (Legal Business Name): LISA D BURNER LCSW CAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 OAKDALE AVE EAST
CRESTVIEW FL
32536
US

IV. Provider business mailing address

259 E OAKDALE AVE
CRESTVIEW FL
32539-3547
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-1234
  • Fax:
Mailing address:
  • Phone: 850-622-1234
  • Fax: 850-689-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2871
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 6803
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: