Provider Demographics
NPI:1518290865
Name:BOURDEAU, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 ISLAND BAY CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6345
Mailing Address - Country:US
Mailing Address - Phone:407-595-6480
Mailing Address - Fax:
Practice Address - Street 1:140 N ORLANDO AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3606
Practice Address - Country:US
Practice Address - Phone:407-622-7177
Practice Address - Fax:407-628-8382
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist