Provider Demographics
NPI:1609265081
Name:BURNSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BURNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 CAMINO DEL LLANO
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-2619
Mailing Address - Country:US
Mailing Address - Phone:505-864-1600
Mailing Address - Fax:
Practice Address - Street 1:1831 CAMINO DEL LLANO
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-2619
Practice Address - Country:US
Practice Address - Phone:505-864-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM067225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist