Provider Demographics
NPI:1386853588
Name:BORDEAU, TRACY ROBYN (COTA)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:ROBYN
Last Name:BORDEAU
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-4411
Mailing Address - Country:US
Mailing Address - Phone:860-589-7054
Mailing Address - Fax:
Practice Address - Street 1:225 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6043
Practice Address - Country:US
Practice Address - Phone:860-482-8563
Practice Address - Fax:860-489-3848
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03236865224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant