Provider Demographics
NPI:1750472841
Name:BURNER, LISA D (LCSW CAP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:D
Last Name:BURNER
Suffix:
Gender:F
Credentials:LCSW CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-1734
Mailing Address - Country:US
Mailing Address - Phone:850-398-6173
Mailing Address - Fax:850-398-6199
Practice Address - Street 1:259 OAKDALE AVE EAST
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536
Practice Address - Country:US
Practice Address - Phone:850-682-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 68031041C0700X
FL2871101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766762100Medicaid