Provider Demographics
NPI:1598748741
Name:DETRAZ, CAROLINE BORDELON
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:BORDELON
Last Name:DETRAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:CHRISTINE
Other - Last Name:BORDELON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 JOHNSON ST
Mailing Address - Street 2:SUITE 100
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 1:204 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4009
Practice Address - Country:US
Practice Address - Phone:337-896-6686
Practice Address - Fax:337-565-6003
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2806225X00000X
LAOTT.200079225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist