Basic Information
| Provider Information | |||||||||
| NPI: | 1740907450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | CHAREST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748465 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303748465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552847483 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 MCMURTRIE DR NW STE C3 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358062470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552847486 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2022 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5079C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.