Provider Demographics
NPI:1235645284
Name:BORDELON, EMILY R (PTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:BORDELON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:B
Other - Last Name:RABALAIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:2002 JOHNSON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3640
Mailing Address - Country:US
Mailing Address - Phone:337-824-4547
Mailing Address - Fax:337-824-4548
Practice Address - Street 1:7406 HIGHWAY 1 STE 102
Practice Address - Street 2:
Practice Address - City:MANSURA
Practice Address - State:LA
Practice Address - Zip Code:71350-4204
Practice Address - Country:US
Practice Address - Phone:318-240-7680
Practice Address - Fax:318-240-7681
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA8539225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant