Provider Demographics
NPI:1275844722
Name:BORDELON, GRETA GREMILLION (LOTR)
Entity Type:Individual
Prefix:MS
First Name:GRETA
Middle Name:GREMILLION
Last Name:BORDELON
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:A
Other - Last Name:GREMILLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LOTR
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-0849
Mailing Address - Country:US
Mailing Address - Phone:337-824-8287
Mailing Address - Fax:337-824-8290
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:71350-4230
Practice Address - Country:US
Practice Address - Phone:318-240-7680
Practice Address - Fax:318-240-7681
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200388225X00000X
LAOTT.200388225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist