Healthcare Provider Details

I. General information

NPI: 1922964709
Provider Name (Legal Business Name): LISA BURNER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2025
Last Update Date: 12/24/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 MAIN STREET SUITE 107
PHILOMATH OR
97370
US

IV. Provider business mailing address

PO BOX 13
PHILOMATH OR
97370-0013
US

V. Phone/Fax

Practice location:
  • Phone: 541-929-5683
  • Fax: 541-929-5684
Mailing address:
  • Phone: 541-929-5683
  • Fax: 541-929-5684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LISA BURNER
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 541-929-5683