Provider Demographics
NPI:1902651433
Name:BOUR, LISA SAMMIE (MA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SAMMIE
Last Name:BOUR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4519
Mailing Address - Country:US
Mailing Address - Phone:954-383-8699
Mailing Address - Fax:
Practice Address - Street 1:3053 ORANGE ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4519
Practice Address - Country:US
Practice Address - Phone:954-383-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22922101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health