=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700320363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA BOURNE LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2016
-----------------------------------------------------
Last Update Date | 06/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 261 NORTH ST
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24201-3275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-821-8030
-----------------------------------------------------
Fax | 423-900-2435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28187 OSCEOLA RD
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24211-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-698-4582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 0701006880
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0710103678
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0718000721
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701006880
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------