Provider Demographics
NPI:1124473442
Name:BURROUGHS, LISA (PHD, MHE, MDIV)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:BURROUGHS
Suffix:
Gender:F
Credentials:PHD, MHE, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 WINDING RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-6159
Mailing Address - Country:US
Mailing Address - Phone:979-777-9241
Mailing Address - Fax:979-268-0207
Practice Address - Street 1:1716 BRIARCREST DR STE 602
Practice Address - Street 2:GALLERIA VILLAGE TOWER
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2751
Practice Address - Country:US
Practice Address - Phone:979-777-9241
Practice Address - Fax:979-268-0207
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX091LB1326 011909101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral