=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124473442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA BURROUGHS PH.D., M.H.E., M.DIV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2016
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1716 BRIARCREST DR STE 602 GALLERIA VILLAGE TOWER
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-2751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-777-9241
-----------------------------------------------------
Fax | 979-268-0207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 WINDING RD
-----------------------------------------------------
City | COLLEGE STATION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77840-6159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-777-9241
-----------------------------------------------------
Fax | 979-268-0207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number | 091LB1326 011909
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------