Healthcare Provider Details

I. General information

NPI: 1700320363
Provider Name (Legal Business Name): LISA BOURNE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 NORTH ST
BRISTOL VA
24201-3275
US

IV. Provider business mailing address

28187 OSCEOLA RD
ABINGDON VA
24211-6400
US

V. Phone/Fax

Practice location:
  • Phone: 276-821-8030
  • Fax: 423-900-2435
Mailing address:
  • Phone: 276-698-4582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701006880
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710103678
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0718000721
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006880
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: