Provider Demographics
NPI:1861797854
Name:BURCH, LISA RENEE (CMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:BURCH
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-0403
Mailing Address - Country:US
Mailing Address - Phone:970-799-2056
Mailing Address - Fax:
Practice Address - Street 1:14324 US HWY 172 NORTH
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-0000
Practice Address - Country:US
Practice Address - Phone:970-563-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2611225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist